Patients put at risk by serious errors at Blackpool Victoria Hospital

The latest incident at the Ophthalmology Department saw a patient given two injections into the wrong eye after the surgeon was interrupted and reviewed another patient’s scan by mistake

The error was one of two ‘never events’ reported to the latest meeting of the board of directors of Blackpool Teaching Hospitals NHS Trust.

Never events are defined by the NHS as serious incidents that are wholly preventable.

A report to the board said: “The lady had been receiving treatment to her left eye, which had resolved and when the surgeon reviewed the scan of her right eye, he was interrupted and reviewed another patient’s scan by mistake and referred the original patient for treatment which was not required.

“The patient came to no harm, but had to undergo two unnecessary injections, with the associated risks involved.”

A previous ‘never event’ in the Ophthalmology Department, reported in January 2020, involved the wrong lens being implanted into a patient’s eye during a cataract procedure at the Ophthalmic Surgical Unit.

Dr Jim Gardner, medical director at Blackpool Teaching Hospitals, said: “We have reported untoward incidents in Ophthalmology before and that has led to a review by the Royal College of Ophthalmology.

“We asked the Ophthalmology Department to bring a detailed action plan to executive which they did a couple of weeks ago, so we really make sure we are confident that our colleagues in the Ophthalmology Department have learned lessons from these incidents and are addressing them.”

In the other incident, a pneumonia patient in the Intensive Therapy Unit had a needle inserted to relieve air pressure into the wrong side of their body.

Dr Gardner said: “The wrong side drain was very quickly spotted and put right and the team in critical care did a very thorough job of analysing what went wrong and learning from it.”

A report to the board of directors said: “The patient had been turned over, however the clinician remained on the same side of the patient and proceeded to perform a needle compression on the left side, instead of the right side.

“This was a time critical procedure as the patient was peri-arrest. The error was immediately recognised and the patient went on to have a needle compression performed on the correct side. This error resulted in the patient requiring a chest drain with its associated harm. ”

Dr Gardner added: “In both these ‘never events’ the outcome for the patients was fine.”

​Thanks for reading. If you value what we do and are able to support us, a digital subscription is just £1 for your first month. Try us today by clicking here