After a C-section, a new mother was misidentifiably fitted with a contraceptive coil because she thought she was another patient in North Wales.
During surgery to amputate two more toes, a patient in North Wales nearly had the wrong toe amputated.
Alleged ‘Never Events’ in Betsi Cadwaladr Hospitals
A third incidence involved the crushing, mixing, and syringing of a patient’s oral medication with water, as the patient was unable to swallow it.
The Betsi Cadwaladr health board area’s hospitals hosted these alleged never events in February.
The hospitals and patients involved in these occurrences have not been made public, but on Thursday the health board will consider them.
“Serious, largely preventable patient safety incident” is how NHS Wales defines a never event: it should not have happened if preventive steps had been taken.
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Never Events in North Wales Hospitals
The silicone remaining inside the patient is a never-occurrence. The Health Board continues to face obstacles. — report
37 never occurrences occurred at hospitals in Wales between April 2021 and March 2022, according to the most recent annual data available.
Ten of the 37 never incidents occurred at the hospitals of the Aneurin Bevan health board in south-east Wales, while the remaining twelve occurred in the Betsi Cadwaldr health board, which serves the entirety of North Wales.
There weren’t any in mid- and west Wales’ Powys or Hywel Dda health board areas.
A patient who underwent a Caesarean section had a coil—an intrauterine device that prevents pregnancy—inserted, according to the Betsi Cadwaladr Health Board’s report on the three cases that occurred in February.
The procedure, which the report referred to as wrong since it was intended for a different patient, was executed incorrectly when the list order was changed due to the increase in category for this patient.
A further occurrence that was labeled as wrong site surgery in the report included a patient whose second and third toes were scheduled to be removed.
They did, however, unintentionally cut their fourth toe.
Fortunately, someone saw the mistake and severed the right toes. A patient who had trouble swallowing oral medication is the subject of the third never occurrence, which is referred to as the wrong route in the report.
As per the investigation, an employee pulverized the substance, combined it with water, and inadvertently injected it intravenously. Incidents may reveal potential weaknesses in an organization’s management of basic safety procedures, according to Chris Jones, deputy chief medical officer of the Welsh government.
He stated that it was crucial to identify them and conduct a thorough investigation. A meeting of the Betsi Cadwaladr health board will take place on Thursday at Venue Cymru, Llandudno, Conwy, to review the three never events that occurred.
A request for comments has been made to the health board.
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