Doctors at Oxfordshire Hospital will now be needing posters to help remind them to check they are treating the right patient to avoid misidentification.
According to a statement released to the media on July 11th 2018, Managers of Oxfordshire’s hospitals have started using posters to help remind staff to check they are treating the correct patient as the number of medical misidentification cases was on the rise.
In a statement, Tony Berendt, medical director of the NHS Foundation Trust, managers of Oxford University Hospitals (OUH) apologised to patients and the public after four serious medical mishaps (referred to as ‘never events’) were recorded between May and June this year – including one endoscopy procedure which was performed on the wrong patient.
Between the months of April 2017 and March 2018, the NHS Foundation trust experienced a total of eight medical mishaps raising a serious cause for concern.
In an effort to reduce the most basic of mistakes, managers of the trust have now put up posters at the John Radcliffe and Churchill hospitals reminding staff to check first and confirm that they are in fact treating the correct patient.
According to a new OUH report, the mantra of ‘right patient every time’ has become a ‘priority’ for the trust after a ‘number of incidents’ of patient misidentification last year.
The report also revealed that the large majority of the mistaken identities during 2017/18 occurred in the radiology department.
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In addition to the posters, oxfordshire hospital staff will undergo special training as part of the action plan put in place by the trust.
Trust medical director Tony Berendt, speaking at an OUH board meeting, said:
“No clinician in our hospital comes to work to be, in any sense, careless or to cause harm. I know that the teams that have been involved in these events are deeply upset about what has happened.
“On behalf of those clinicians I would extend my apologies to all patients involved and our public for the inevitable impact on their confidence in our services that these kind of events lead to. We do take them extremely seriously. We are transparent about them, as is evident in this report.”
The trust, which also runs Banbury’s Horton General Hospital, revealed four ‘never events’ had been declared in the months of May and June this year.
Such events, which can include misidentification of patients, are defined by the NHS as ‘largely preventable’ incidents that should not occur if healthcare providers are following national guidance or safety recommendations.
The report said a lack of Positive Patient Identification and staff distraction were major risks contributing to these incidents.
One incident involved staff carrying out an endoscopy procedure on a different patient than the one intended.
The report notes that it was “fortunate that both patients required the same test”.
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Another saw a ‘sizing trial cup’ left inside a patient following an orthopaedic operation; the patient had a second operation on the same day to remove it.
A third incident involved a patient who should have received anaesthetic receiving a different form of injection – this was recognised part of the way through the procedure and the correct injection was the given.
Meanwhile, surgeons forgot to remove a vaginal pack following a gynaecological operation after the surgical team failed to make a note of it. The pack was identified the morning after surgery and removed.
Oxfordshire Hospital, which says it is committed to learning from such events, said the new posters were currently for ‘internal staff communications’ only, but work on an external poster was underway.
Spokeswoman for OUH, Natalie Ellis said:
“These poster reminders are part of a suite of actions to remind staff to thoroughly check a patient’s identity, and this work is a planned part of our Quality Priorities which aim to achieve very high levels of reliability in all our safety processes.”