DOCTORS have been banned from using abbreviations for ‘left’ and ‘right’ after a patient had the wrong area of his back operated on – twice.
Bosses at Oxford University Hospitals (OUH) have taken the steps in an effort to avoid any future medical mix-ups following the botched mole removal earlier this year.
According to trust documents, the alarming error was initially picked up in March when the patient returned to the dermatology department at the Churchill Hospital to receive their results from the minor op.
Realising their mistake, doctors then promptly booked the patient in for a second procedure to remove the correct lesion, however, again the wrong area of skin was removed, meaning a third procedure was required.
An OUH report states that after the incidents (which the NHS refers to as a ‘never events’) were highlighted, trust chiefs took ‘immediate action’, including the banning of ‘abbreviations for ‘left’ and ‘right’ on Dermatology documents and ensuring that theatre staff are present at check-in and are ‘actively involved in surgical site confirmation’.
The trust, which also runs the John Radcliffe Hospital in Headington and the Horton General in Banbury, confirmed a full investigation had been carried out following the incident.
The worrying incident comes as new provisional figures reveal the number of ‘never events’ recorded at Oxford University Hospitals rose to 10 between April 2018 and March 2019 - an increase on the previous year's total of eight.
Never events are defined as ‘serious incidents that are wholly preventable’ if correct procedures are followed.
However, in the last year doctors at the trust have operated on the wrong area four times, while patients were left with ‘foreign objects’ inside them following operations on five occasions.
One further serious error where a patient was given air instead of oxygen was also recorded.
Deputy medical director at the trust, Clare Dollery, said: “We take every never event very seriously, and we are very sorry for what happened to this patient.
"As with every never event, we reported these errors to the relevant regulators and carried out a full investigation. We will be taking steps to ensure that staff are aware that abbreviations should not be used in this context.
“Preventing never events is a trust-wide quality priority for us, and there is an improvement plan in place that we will take through into 2019/20.
“Our trust carries out tens of thousands of successful operations and procedures every year. It is difficult to eliminate human error completely, but we use a variety of different training techniques including Human Factors Training, safety checklists, and encouraging staff to challenge colleagues with any concerns to reduce the opportunity for error.”
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