The mistake was branded a 'never event' because they are never supposed to be allowed to happen
Another of the ‘never events’ was classed as ‘moderate harm’. That involved a ‘retained swab’ – a swab used during surgery which mistakenly left inside the body. Officials say safety action posters were put up in response. A second ‘retained swab’ incident was classed as ‘no harm’ after an investigation.Two incidents were classed as ‘low harm’. One of these saw a procedure performed on the wrong lesion, leading to an immediate safety reminder for staff, and an investigation.
A final ‘never incident’ was recorded as ‘no harm’ and involved a surgical implant which had exceeded its expiry date. It led to a check of all stocks in the hospital and a review of the process to manage stock rotation, as well as education in operating theatres relating to requirements of supervision of trainees.The Care Quality Commission inspection report published on April 5 this year reported that the trust declared 11 never events during the period September 2020 to May 2021.
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