Bristol surgeons' op on the wrong organ

SURGEONS at a Bristol hospital performed an operation on a patient's wrong organ, it has emerged.

The patient suffered some "long-term harm" after the procedure but North Bristol NHS Trust (NBT) would not reveal details about which organ was involved.

The incident, which has been blamed on the patient's "distorted anatomy", happened during the 2011/12 financial year.

The trust says the patient, who has not been named, has now fully recovered, been informed and received an apology.

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It was one of two incidents that are classified as "never events" that occurred at the Frenchay and Southmead trust during the year.

They are called never events because if appropriate precautions are taken they should never happen.

However, the hospital trust has said that the complicated nature of the patient's anatomy meant the error could not have been prevented by using the usual measures.

In another operation a surgical clamp was left inside a patient after surgery and had to be removed during another procedure.

Details of the incidents were revealed in a report compiled by the hospital trust along with the details of the lessons learned.

As a result of the clamp being left inside a patient's body the trust said a new policy had been written calling for counts of swabs, medical instruments and needles and if any are missing after surgery an X-ray should be carried out to check if items have not been removed.

In the case of the procedure being carried out on the patient's wrong organ, the trust said it was down to "human error due to distorted patient anatomy".

The trust said: "The consultant surgeon was experienced and assisted by a specialist in the patient's condition. The World Health Organisation Surgical Checklist was used correctly, and as such, could not have presented this error."

As reported in the Post in April a patient died at the city centre hospital trust following issues with the removal of medical equipment.

The never event at University Hospitals Bristol NHS Foundation Trust (UHBristol) led to the unnamed patient dying in intensive care in March. They had suffered an air embolism – where a significant amount of air gets into the blood vessels causing a blockage – which was believed to have occurred during the removal of a central line – a hollow tube inserted through the chest into a vein to give treatments or take blood.

There was also a never event at UHBristol when a chest drain – a tube inserted into the chest to drain fluid or air – was put into a patient on the wrong side. It did not cause significant harm to the patient but had to be removed and inserted again on the right side.

Director of nursing at NBT Marie-Noelle Orzel previously said: "Never events should never happen.

"However, it is important to stress that these incidents are incredibly rare – to put this into context, last year North Bristol NHS Trust cared for almost 113,000 inpatients and day case patients, the majority of which would have undergone a surgical procedure.

"By its very nature healthcare can be high risk and at times unpredictable. Patient safety is one of this trust's top priorities and we have led the way nationally and internationally in developing various systems and processes that have successfully reduced the level of risk for patients."