List of "never events" at Jersey General Hospital 2010 to 2015 (FOI)List of "never events" at Jersey General Hospital 2010 to 2015 (FOI)
Produced by the Freedom of Information officeAuthored by States of Jersey and published on
10 March 2015.Prepared internally, no external costs.
Request
Please could you list all the 'never events' at Jersey's General Hospital for each of the past five years. Never events include incidents such as leaving medical equipment inside a patient after an operation or a death that should not have occurred.
Please give a summary of each incident, including the age and sex of the patient involved, and where known the outcome of any subsequent investigation, and a copy of the investigation report (appropriately redacted to avoid identifying the patient).
Response
Never events are a recognised set of specific incidents which are seen to be largely preventable if available protective measures have been implemented.
Below are Health and Social Services incidents 2010 – 2015 which were classified as ‘Never Events’ according to the published list:
| 2010 | None |
| 2011 | Wrong Site Surgery A skin lesion was removed under local anaesthetic in an outpatient clinic. The patient had to undergo a second procedure to remove the correct lesion. Moderate harm, patient required further outpatient procedure. Root cause analysis investigation undertaken: Improved checking processes implemented in the outpatient setting. |
| 2012 | Wrong implant/prosthesis A patient received the incorrect 'side' prosthesis. This was identified at the end of the operation; the patient was notified and then was required to undergo further surgery. Moderate harm, patient required further inpatient procedure. Root cause analysis investigation undertaken: A number of changes were made to strengthen the theatre checking processes which are subject to regular audit. |
| | Retained foreign object post operatively Following a procedure under local anaesthetic, a swab was left in situ. This was removed without the need for an operative procedure. The patient required some additional treatment. Moderate harm, patient required further outpatient treatment. Root cause analysis investigation undertaken: A number of actions were made to improve adherence to standard checking processes and are subject to regular audit. |
| 2013 | None |
| 2014 | None |
| 2015 | None (reporting timeframe to 28 February 2015) |
The age and sex of the patients involved will not be provided; given the small numbers this would constitute patient identifiable information. Reports will not be provided as redaction of patient identifiable information would make the reports nonsensical.
Therefore, this request is exempt under article 25 (2) of the Freedom of Information (Jersey)
Law 2011 (see exemption detail below).
In each of the three cases an investigation took place in order to establish the cause of the problem and identify what measures could be implemented to provide additional safeguards in the future. In each case, the key lessons were incorporated into revised procedures – our procedures are checked regularly through audit processes.
The welfare and safety of patients is our key priority, and the number one aim of our
investigations into these cases is to strengthen our systems with the aim of minimising any risk of repetition. Our approach is to achieve even higher standards of patient care, through the ongoing improvement of systems.
Exemption
25 Personal information
(2) Information is absolutely exempt information if:
(a) it constitutes personal data of which the applicant is not the data subject as defined in the Data Protection (Jersey) Law 2005; and
(b) its supply to a member of the public would contravene any of the data protection principles, as defined in that Law.
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