New health board to tackle professional negligence
After an independent report exposed a huge amount of professional negligence practices occurring during brain surgeries, a campaign has been launched to provide better patient care.
The movement looks at the cases of 14 brain surgery patients who were the victims of medical negligence when neurosurgeons operated on the wrong side of the head.
As a result, health officers and experts are launching a government drive to make operations safer and to also improve health standards.
The 14 brain surgery patients had suffered head personal injury causing bleeding in the brain, leading to increased pressure in the head.
The standard treatment is to drill holes in the skull to release the pressure, but in the 14 cases the ‘burr-holes’, were drilled on the wrong side. A second set of burr-holes then had to be drilled on the correct side. The 14 cases, all in the UK, were reported to the National Patient Safety Agency over the past three years.
Sir Liam Donaldson, the Government's chief medical officer, will highlight the cases at the launch of his yearly report when he will announce the creation of a new clinical board for medical protection to decrease blunders and eradicate ‘wrong site’ mistakes.
Medical mistakes high
Around 7.9 million operations are performed in the UK annually, nearly 10 times the number of births, yet surgical safety offers far less attention than the wellbeing of maternity care.
In 2007 one patient a day was listed for incorrect surgery, and there were 1,136 errors involving operating lists, including mistaken surgery, wrongly identified patients or operations performed in the wrong place.
More than one operation a month in the same year– 16 in all – was done on the wrong site. Examples include cochlear implants – surgically implanted hearing aids – in the wrong ear, removing bone from the wrong foot, wrong incisions to gain access to organs in the abdomen and knee replacements on the wrong (healthy) knee.
Overall, nearly 130,000 blunders involving surgical procedures were reported to the National Patient Safety Agency. In most cases involving operating lists, the error will have been detected before the surgery was done so the true number of errors is likely to be under-reported.
Sir Liam stated: “The procedure of drilling burr-holes can be life-saving and you could say that it is a low number [drilled on the wrong side] in the context of all neurosurgical cases.
“But many people would be incredulous that it could happen at all, let alone be repeated. It is a challenge to our ability not just to reduce error but to ensure these sorts of error do not happen. They should be 'never events'.”
He added: “Most surgery is safe but errors do occur. Many are minor but some are serious. Some should be 'never events'. We really should be able to consign wrong-site surgery to the history books.”
The new medical panel will be established by the National Patient Safety Agency and includes the Royal Colleges of Surgeons and Anaesthetists and patient organisations.
Its primary objective will be to challenge wrong-site neurosurgery and fatal reactions to cemented hip replacements. Sir Liam will also call for safety tests based on a checklist to be piloted in all UK hospitals.
Updated on 4/6/2010