Man is circumcised by MISTAKE after surgeons mixed up his paperwork
Man who went to hospital to have a bladder check-up is accidentally CIRCUMCISED when NHS surgeons mixed up his paperwork with another patient’s
- The unnamed man incorrectly went under the knife last September
- His notes became mixed up with a man who was meant to have the procedure
- One of eight ‘never events’ at University Hospital of Leicester NHS Trusts in 2018
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A man has been circumcised by mistake after surgeons confused him for another patient.
An NHS report reveals the man – who has not been named – was scheduled to have his bladder inspected via a thin camera in a cystoscopy.
But the patient’s notes became mixed up with those of a man who was due to be circumcised last September.
The case is one of eight ‘never events’ that took place at University Hospital of Leicester NHS Trust last year.
A man has been circumcised by mistake after surgeons confused him for another patient. The case is one of eight ‘never events’ that took place at University Hospital of Leicester NHS Trust – which includes the Leicester Royal Infirmary (pictured) – last year
‘Never events’ are serious, preventable mistakes that are considered so shockingly bad they should never occur.
They also cover operating on the wrong patient or the incorrect part of the body.
Leicestershire Live asked the man’s age, with the trust confirming he is an adult but saying further details are ‘irrelevant’.
The trust also denied to answer exactly how the error came about.
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NEVER EVENTS AT UNIVERSITY HOSPITAL OF LEICESTER NHS TRUST IN 2018
January: Unintentional connection of a patient requiring oxygen to an air flow meter (measures how much air is moving through a tube)
March: Swab left in a child who underwent surgery to remove small lumps of tissue at the back of his nose
April: Unintentional connection of a patient requiring oxygen to an air flow meter
AND
Man had incorrect surgery due to him having a similar name to another patient
May: Patient had incorrect surgery due to the consent process not being robust enough. Failure to learn from a previous never ever was listed as a factor
June: Patient had an X-ray on their blood vessels in an incorrect place. Failure to learn from a previous never ever was listed as a factor
September: Man was circumcised when he consented to a bladder inspection. Failure to learn from a previous never ever was listed as a factor
November: Hip implant was fitted to the wrong side of a patient
The report – by Leicester City Clinical Commissioning Group (LCCCG) – also revealed the trust left a swab inside a child following nasal surgery.
And in April, a patient had surgery meant for a man with a similar name.
In yet another blunder, one patient even had a hip implant fitted on the wrong side.
‘Failure to demonstrate learning from never events has been a concern for Leicester, Leicestershire and Rutland commissioners and partners for some time,’ the report states.
‘The CCG [clinical commissioning group] has an important role in continuing to support UHL to achieve their quality and safety ambitions, and intends to do this modelling the comprehensive and collaborative approach described within the CQC [Care Quality Commission] report.
‘This will be achieved through continuing to strengthen our relationships and aligning our improvement approach around a common set of clinical priorities.’
Moira Durbridge, director of safety and risk at Leicester’s Hospitals, said: ‘We remain deeply and genuinely sorry to those patients involved, and of course we have personally apologised to each one.
‘We are committed to learning and improving and have enshrined this work into our clinical priorities within our quality strategy for 2019/20.’
Chris West, director of nursing and quality at Leicester City Clinical Commissioning Group, added: ‘We appreciate the distress these incidents cause to patients and their families.
‘As commissioners, we monitor closely the number of patient safety incidents and serious harm reported during a patient’s stay at the University Hospitals of Leicester.
‘And are working with the trust to support them to improve quality and safety for patients.’
DOES SURGICAL EQUIPMENT EVER GET LEFT IN PATIENTS’ BODIES? AND WHAT ARE THE RISKS?
Surgical items left in the bodies of patients can cause sepsis and even death.
In less severe cases, people may experience pain, discomfort and bloating.
In the US, up to 6,000 surgical instruments are left inside patients’ bodies every year. Of which, around 70 per cent are sponges and the remainder items such as clamps.
Dr Atul Gawande, a surgeon at Brigham and Women’s Hospital, said: ‘In two-thirds of these cases, there [are] serious consequences.
‘In one case, a small sponge was left inside the brain of a patient that we studied, and the patient ended up having an infection and ultimately died.’
Such mistakes are considered so shockingly bad they are often referred to as ‘never events’, which also covers operating on the wrong patient or part of the body.
In 2004, the Joint Commission, a US-based nonprofit organisation, published the Universal Protocol, which provides guidelines on how to reduce such never events.
These recommendations include ensuring all medical equipment is accounted for at the end of every procedure, however, this can be challenging considering up to 100 sponges may be used in a single major operation.
Errors also often occur in stressful situations, when changes to the operation procedure happen suddenly or if there are a lot of distractions.
Dr Ana McKee, executive vice president and chief medical officer of the Joint Commission, told CNN: ‘If there’s music going on or side conversations or someone is on the phone, that does not meet the spirit of the Universal Protocol.’
Many hospitals in the US have switched to sponges and surgical tools with barcodes on them so they can be electronically tracked.
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