An investigation into a series of surgical blunders in which items of medical equipment were left inside patients at Sheffield hospitals has found no evidence of a ‘systemic safety problem’.
The external review was commissioned by Sheffield Teaching Hospitals NHS Foundation Trust and the city’s Clinical Commissioning Group after the foreign objects – mainly swabs and dressings – were left inside 11 patients by mistake from 2010 to 2013.
The incidents were classed as ‘never events’ by the Department of Health, and a report of the investigation has set out 45 recommendations to reduce the risk of similar errors happening again.
The report, written by patient safety expert Professor Brian Toft and Dr Alex Grice, said: “Following a review of all appropriate documentation, observing operating theatre procedures and undertaking interviews with crucially placed staff no evidence has been found to suggest that Sheffield Teaching Hospitals has an unrecognised systemic patient safety problem.
“On the contrary, the evidence indicates that, apart from a number of outliers, the vast majority of the activities undertaken with respect to patient safety meet the highest standards. However, where there appears to be room for improvement recommendations have been in those respects.”
Prof Toft and Dr Grice also found the mistakes ‘appeared to have taken place at random’ and that no member of surgical or theatre staff was involved in more than one of the incidents.
New measures include making sure surgeons only use accountable items – such as swabs and needles – if they are handed to them by a scrub nurse, except if a patient’s life is in immediate danger. All anaesthetists will receive training in swab checks, and the hospital trust has been asked to carry out a risk assessment around the use of cotton wool balls in its operating theatres.
But the report warned: “Regardless of what precautions are taken there is always the possibility that a serious untoward incident could occur.
“Thus the recommendations, when implemented, will reduce the risk of patients experiencing the inadvertent retention of a foreign object following a surgical or invasive procedure at Sheffield Teaching Hospitals.
“However, what they cannot do is guarantee that this type of serious untoward incident will never happen again.”