Inquiry launched after Northamptonshire hospital patient gets drug injection in wrong eye
Incident is the second 'never event' at NHS Trust this year
A medical blunder led to a drug with potentially serious side effects being injected into the WRONG EYE of a Northamptonshire hospital patient.
Kettering General Hospital, now part of University Hospitals of Northamptonshire NHS Group, launched a serious incident investigation after the mix-up.
April's incident is the KGH trust's second 'never event' this year — the type of medical mistake which should never happen.
The affected patient was given a Lucentis injection — a prescription medicine often used for the treatment of people with wet age-related macular degeneration — into the wrong eye although the level of harm caused as a result of the mistake is not known.
Lucentis safety information warns side effects can include detached retinas, cataracts and serious eye infections. The drug’s website also warns of fatal complications in the most serious cases, related to blood clots including heart attacks and strokes.
The incident was discussed by the hospital's serious incident review group on April 22 but the trust blocked a bid by this newspaper to release minutes of the meeting under Freedom of Information laws.
KGH said 'immediate learning' was shared with the relevant team and that a serious incident investigation will now look at whether appropriate checks were made, long-term harm to the patient, what assessment was made of the patient's capacity and whether there were any staffing shortfalls.
Director of governance, Richard Apps, said: “We treat all incidents affecting our patients and staff with a great deal of care and close attention and will always seek to address areas of learning and improvement that arise from our investigations. We work closely with patients and families concerned in a completely confidential way and cannot comment on individual incidents.
“We can comment on how we deal with serious incidents, including never events, in patient care and the process that we follow to ensure that we fully investigate what happened and ensure the patient or family affected know exactly what we are doing to prevent such incidents happening in the future.
“We follow a nationally recognised serious incident framework which is a very thorough way of identifying what went wrong, why it went wrong, and what can be done to prevent similar events recurring in the future.
“This involves interviews with staff and a detailed investigation of the patient’s care. We then work closely with the patient or family concerned and keep them informed of the investigation. We would always apologise and give the patient or their family a copy of the final incident report and enable them to discuss its findings and any remaining concerns.”
Another 'never event' at the hospital in February saw a self-caring, independent patient disconnect his prescribed oxygen tubing from the wall oxygen flow meter and connect it to a portable cylinder to mobilise.
KGH said that on returning to his bed he inadvertently connected the oxygen tubing to the medical air flow meter. They said that when identified this was immediately rectified and the patient's oxygen levels returned to within his expected range.
The patient subsequently died but the hospital said the incident was not deemed to have contributed. They said immediate actions were taken to ensure air points are capped and all staff were reminded to not allow patients to connect and reconnect oxygen.
Prior to February the last never event at KGH was in November 2019, although details of the incident were not made public.
A hospital spokesman said that while never events and other serious incidents are relatively rare they are working with colleagues in Northampton, as a hospital group, to look at how they share and embed learning from patient safety incidents.
They added that they are planning group-wide events in the near future to share learning and further develop best practice approaches.