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Wrong Site Surgery & Other Never Events

View profile for Sylvia Taylor
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The NHS describes Never Events as ‘serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level and should have been implemented by all healthcare providers.

Each never event type has the potential to cause serious patient harm or death.  However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a never event’.

The Never Events Policy Framework was last revised in 2015 and the data is available on the NHS Improvement website.

The revised framework states that the patient/family/carer must be informed as soon as possible when a Never Event occurs.  However, wrong site surgery will not be considered a Never Event if, for example, the wrong site is selected because of unknown/unexpected abnormalities in the patient’s anatomy or where the wrong site is due to incorrect laboratory reports/results or incorrect referral letters.

Surgical errors include wrong site surgery, wrong implants/prosthesis and a retained foreign object after a surgical/invasive procedure.

The NHS have procedures in place which should prevent these never events.  These include, where applicable, the marking of the surgical site.  Before the start of any surgical intervention, the surgeon should be aware of the patient’s name, the nature of the procedure, the site and position that is planned.

Despite the fact that these types of errors should be rare, nevertheless, we have represented two clients recently where such an error has occurred. In one case we obtained compensation for a client whose finger was correctly marked, yet the surgery was carried out on a different finger. 

We also acted for a client where the surgeon had a long list of patients and had failed to check the name of the patient and the planned procedure.  It was only when a member of the theatre team brought to his attention that he was performing the wrong operation that the correct operation was then carried out.

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