Mistakes put Bristol hospital patients at ‘high risk’
THOUSANDS of patients were put at risk last year due to mistakes by staff in Bristol hospitals.
The Evening Post can disclose that, in 2009/10:
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* In Frenchay and Southmead hospitals, a total of 28 people died after mistakes were made;
* There were more than 9,500 incidents across the Bristol area where patients could have suffered harm;
* At the Bristol Royal Infirmary, three patients were put at “high risk” due to errors connected to medication;
* At Weston General, there were 54 mistakes involving medical equipment;
* There were eight serious incidents at the maternity units in the North Bristol NHS Trust
(NBT), which runs Frenchay and Southmead;
* More than 300 wrong or inappropriate procedures were carried out in Bristol and Weston-super-Mare.
The figures also show more than three mistakes were made in prescribing and giving medication at hospitals in the Bristol area every day.
In the cases where 28 people died, it is unclear whether or not the incidents caused the patients’ deaths.
The Evening Post obtained details of errors that could have led to patient harm last year.
The results showed that 831 medication errors of varying levels of seriousness were made at the nine city centre hospitals, including Bristol Royal Infirmary and the children’s hospital.
There were 114 errors involving medication at Weston General, 92 cases where tests, results, scans and records led to incidents where patients could have come to harm and 54 issues involving medical equipment.
North Bristol NHS Trust (NBT), which runs Frenchay and Southmead hospitals, responded to the Freedom of Information request with just the serious incidents that occurred at the health trust within the year.
Issues in the maternity unit accounted for eight serious incidents, errors with medication were involved in seven cases and delays or failing to follow up test results led to six.
The hospitals would not provide specific examples of cases at the hospitals to protect the confidentiality of the patients involved.
Of the errors at the BRI, three medication errors were high risk, there was one case where high levels of risk were caused by wrong or inappropriate procedures and five falls in that category.
At Bristol Children’s Hospital there were three high risk medication errors, and three incidents where a wrong procedure was carried out.
Weston General did not categorise incidents by their seriousness, although they told the Post that most of the incidents recorded were in the most minor category.
While the numbers of errors reported by the health trusts every year run into the hundreds, about 1.4 million patients are seen in the wider Bristol area every year, and hospital managers pointed out that staff are encouraged to report every incident that occurs so that they can be fully investigated and lessons learnt so worse mistakes are prevented.
Incidents are reported to the National Patient Safety Agency and details of any common incidents from hospitals across the country are communicated to all NHS trusts.
Hospital managers said that falls are common due to the high numbers of older patients who are admitted. Often the patient is not at serious risk, but if they break certain bones or suffer a head injury it can end in a fatality.
Medication errors can range from a patient almost being given the wrong dose but checks preventing it from happening to the wrong amount being administered.
The medical director at UHBristol, Dr Jonathan Sheffield, said that the trust uses automated prescribing in departments with the most vulnerable patients, such as intensive care and oncology. The computerised system means that checks are in place to prevent doctors prescribing doses that are too large. There are plans to bring the procedure in across the hospital trust in the future.
NBT and UHBristol were involved in a safer patients pilot that involved recording details of incidents along with hand hygiene and other elements.
Director of nursing at NBT, Marie-Noelle Orzel, who joined the trust several months ago, said: “Coming into the trust none of the errors are that different to what I would expect to see.
“I would be worried if there were very few reported incidents.
“I don’t think a hospital in the country can say they do not have any incidents.”
Dr Sheffield said: “We want a culture where everyone reports everything. Often if there is a critical incident, you look back and find there have been near misses that involved similar circumstances and could have prevented the more serious incident.”
Spokeswoman for Weston Area Health Trust, Caroline Welch, said: “Any member of staff who is concerned about an incident or a system failure which they consider may put someone at risk is encouraged to report it.
“Incidents are then risk-assessed on a red, amber, green rating scale and of these 2,030 incidents in 2009/10, 1,650 were in the most minor category.”
Chairwoman of patient and public representative group Link’s (Local Involvement Network) Bristol acute hospitals group, Gill Maw said she was surprised there was such a number of incidents and errors at hospitals in the city.
She said: “I am somewhat concerned about the number of cases although we perhaps do not know them all. In the future trusts need to be much more transparent.”
The Evening Post has previously reported that in 2007 University Hospitals Bristol NHS Foundation Trust (UHBristol), which runs the children’s hospital and royal infirmary published the findings of an investigation into a massive overdose of a drug given to four young cancer patients.
They received doses 500 times stronger than intended but did not suffer as a result.
Last year there was an inquest into the death of a mother who died after she was given four times the amount of a chemotherapy drug as she should have been due to an error made by the Frenchay hospital doctor who prescribed the medication.
Comments
by Alex, Redcliffe
Tuesday, July 20 2010, 9:38AM
“Hmm. That didn't appear although it will probably come up twice now later in the day. Let's try again though:
I have to say I am incredibly disappointed by this article and will be making a complaint via the Press Complaints Commission. Why? Because yet again the Evening Post have taken a set of figures and manipulated them to concoct a story to try and sell papers in a misleading manner, completely throwing balance or context out of the window. This would be in contravention of the Press Complaints Commission Editor¿s Code 1 i) in relation to publishing misleading information.
First, the headline is designed to scare people and gives no context. It simply refers to ¿Bristol hospital patients¿ when in actual fact, only 9,500 are then mentioned further down. This is the second issue, as these people only ¿could have suffered harm¿. Not ¿did¿ but ¿could have¿. Again, misleading as the opening sentence says they were put at risk when in actual fact they could have been put at risk but probably were not.
Next, it is only when we get to half way through the article that we finally see a bit of context ¿ 1.4million patients treated across Bristol from which we get this 9,500 figure. So that is, if my maths are correct, 0.68%!
Finally, and again we are lacking context. How have these figures changed year-on-year? If this is worse than last year, i.e. there are more mistakes being made, then it is in the public interest. I am guessing that the figures actually improved and so they were left out as it would not suit your agenda to include them. However, this is surely in breach of the guidelines and could be considered grossly misleading as readers are not being given the full picture in context.
Overall a shoddy piece of journalism designed to shock and sell papers without maintaining basic standards of journalistic and editorial integrity.”
by anan, bristol
Monday, July 19 2010, 11:31PM
“its a miracle any baby gets to be born alive from southmead hospital when high risk babies / mothers are being refused within a couple of hours of delivery. Fatalities, serious complications, trauma etc should not be abandoned to chance and negligence of staff. conditions are truly appalling.”
by anon, bristol
Monday, July 19 2010, 11:24PM
“its a miracle any baby gets born alive at southmead hospital - pre birth treatment is appalling -high risk babies /mothers are being turned out of the hospital a couple of hours pre delivery., leading to fatalities, mental retardation and serious..complications”
by Annette Hennessy, Portishead
Monday, July 19 2010, 6:57PM
“You are wrong Judith Miller because I have read many reports and letters from people praising the NHS in the Bristol Evening Post alone. However while there is much good work in the NHS, there is also some poor and if you are one of those affected, it can be quite devastating especially if the unsatisfactory care contributes to a patient's death or if it affects the quality of their last few weeks or days. The NHS complaints process is long and arduous which is why so many people contact the press. I know, I have been there. Not wishing to proceed down the litigation route but just to get an apology and to prevent the same thing happening to another patient.”
by Christine, Bristol
Monday, July 19 2010, 6:54PM
“The comments below say it all and I'm so pleased that they (well, the majority) are sensible.
The mistakes would've been followed up with a Significant Event Analysis and hopefully procedures would be amended and everybody will have learnt from the incidents.
Shame the BEP can't report how many of these mistakes were made by overworked and underpaid medically trained staff but then that's a whole new rant I could have!!
Keep up the good work, Bristol hospitals!”
by Gareth, Bristol
Monday, July 19 2010, 5:11PM
“Figures aren't in context so don't mean an awful lot.
How many cases do they see a year - 3-4 million? more? less? without that it's impossible to see what these mean and it's lazy journalism”
by George/Pedro Mendes/Roger, Ooooh, I'm confused. 'NURSE'........
Monday, July 19 2010, 5:00PM
“Well, they certainly cocked up my lobotomy................”
by Jon, Bradley Stoke
Monday, July 19 2010, 4:43PM
“The Evening Post is turning into a really nasty, vindictive publication.
It's almost as if it was operating to the same editorial standards as the Daily Mail... hmmmm...”
by Esme, Bristol
Monday, July 19 2010, 2:43PM
“I think this headline says more about the BEP (and it's not flattering) than it does about the NHS and it seems most of the comments show that people have realised this.
Of course the NHS is not perfect (who or what is?) but I believe they are doing their best to root out these errors and stop them happening again.”
by Judith Miller, Bristol
Monday, July 19 2010, 2:35PM
“You'll never see an article in support of the NHS in a Northcliffe publication.”