Surgeries performed on the wrong patient, wrong body part or cases where the wrong surgical procedure was carried out on a patient were all serious events reported in Irish hospitals over a one-and-a-half year period.
"Foreign objects" left inside the body after operations and incidents including sexual assault on patients are all included in a detailed breakdown of "serious reportable events" in Irish hospitals, published by the Health Service Executive (HSE) yesterday.
Over 19 months from March 2014 to September 2015, 233 serious incidents were logged by medical staff as part of an initiative to help staff learn from their errors.
In 100 of the incidents the patient in question later died although the report stresses this does not necessarily mean death was as a result of the mishap reported.
Serious
“It is incumbent on all healthcare staff and managers to understand what went wrong, to learn from it and to respond,” the HSE report says, explaining that events in question relate to both avoidable and unavoidable scenarios.
Included in the breakdown of serious incidents are three cases of surgery performed on the wrong body part; one case of surgery performed on the wrong patient; another involving the wrong surgical procedure on a patient and 14 incidents of the “unintended retention of a foreign object in an enclosed body cavity after surgery”.
Surgery
The vast majority of incidents (174) happened in acute hospitals with most relating to issues of care management (103), followed by “environment” (57) and surgery (23).
Sixteen cases involved the death of a baby and there were 12 incidents reported of “sexual assault on a patient or other person within or on the grounds of a healthcare service facility”.
There was one case recorded of “patient death or serious disability associated with the use of contaminated medications, medical devices or biologics” and six deaths or serious disability cases involving the use of a medical device for “functions other than as intended”.
While the report lists a significant number of serious errors, the HSE says the context is important.
It says public acute hospitals treat 1.4 million patients every year. There are 3.2 million outpatient attendances and 1.2 million attendances at emergency departments.
Every year, 68,000 babies are delivered in maternity units.
