Wrong-side injection never events

Investigations have taken place after two patients were injected on the wrong side of their bodies at the same hospital within a month, a report says.

County NHS bosses said that the “never events” – the NHS term for preventable serious accidents – took place at the Robert Jones and Agnes Hunt Orthapedic Hospital near Oswestry, in April.

The hospital’s governing trust took “immediate remedial actions” and reports on both mistakes are expected this month, said Clinical Commissioning Group performance director Julie Davies and assistant quality director Tracey Slater.

The Shropshire, Telford and Wrekin CCG governing body will discuss their report when it meets on Wednesday, July 14.

“One incident involved a Shrewsbury and Telford Hospital NHS Trust member of staff working at RJAH,” Dr Davies and Mrs Slatersaid.

“However, following fact-finding this never event has been attributed to RJAH with support from SaTH to complete the report.

“Both incidents are undergoing investigation and reports are due in July.

“Assurance has been sought from the trust who have taken immediate remedial actions.

“Further to this, members of the CCG quality team have undertaken a visit to the trust and gained assurance of implementation of changes.”

An Integrated Performance Report presented to the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust directors on May 27 said: “There were two never events reported in April.

“One related to a patient given an injection in the wrong hand and the second a wrong-sided anaesthetic block was given [sic].”

An anaesthetic block refers to local anaesthetic being injected close to a nerve.

Minutes of the directors’ April 29 meeting discussed one of the incidents and say RJAH chief executive Mark Brandreth “confirmed that the patient is fine”.