'Cardiology procedure' carried out on wrong patient in hospital mix-up

A patient underwent a medical procedure intended for someone else after a mix up at a hospital trust.

The North Tees and Hartlepool NHS Foundation Trust said an “invasive diagnostic examination” was carried out on the individual. But staff then realised the request for treatment had been made for the wrong patient.

A spokesman for the trust said it had been a cardiology procedure, but would not elaborate any further. Cardiology is the branch of medicine that deals with disorders of the heart and related blood vessels.

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The mix-up, which took place at the end of January, was initially reported as a so-called ‘never event’ and then escalated to a serious incident a few days afterwards.

The North Tees and Hartlepool NHS Foundation Trust said a 'never event' had occured at one of its hospitals

The trust said the patient in question had been aware of the error and was unharmed and the correct patient had now had the required investigation.

A spokesman said: “We can confirm that earlier this year a day-case cardiology procedure was carried out on a patient who did not require this particular diagnostic investigation. We have fully apologised to the patient who has suffered no adverse effect from the procedure.”

The trust, which operates hospitals in Stockton and Hartlepool and serves a population of about 400,000 people, would not say how exactly the blunder occurred or what the outcome was of the inquiry that resulted.

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The spokesman added: “Our trust culture is to take any such incident very seriously but not to lay blame on individuals. We always seek to learn and thoroughly investigate to ensure we develop robust processes to prevent a repeat occurrence.”

It was reported last month how another serious incident was declared at the trust after an intermittent error affected the use of an electronic patient record system.

The NHS defines serious incidents as where the “potential for learning is so great or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response”.

Meanwhile, never events are events that should be entirely preventable through following and implementing guidance and safety recommendations.

When a never event is recorded by a trust it is intended to act as a red flag to make improvements.

In July last year the South Tees Hospitals NHS Foundation Trust reported a never event which occured when a clip used in a surgical procedure on a brain surgery patient failed to be removed from a flap of skin.

The clip was then removed while they were still in hospital as part of an already-planned second operation with the hospital trust later introducing a new process around the documentation of skin clips to help prevent another similar occurrence.

Never events largely result from errors in treatment, but can also include incidents such as patients falling from windows, becoming trapped between a bed rail or in a bed frame or mattress and the scalding of patients when washing/bathing.