A CATALOGUE of shocking surgical blunders including a patient being left with a piece of plastic in their neck have raised further fears over the safety of Lothian operating theatres.
The Evening News revealed yesterday that an internal probe – sparked after a patient was allowed to fall headfirst from an operating table while under general anaesthetic and another had two stints in intensive care due to being sewn up with a swab still inside them – had found a series of deep-rooted issues within NHS Lothian surgical teams which potentially put lives in danger.
Today, details of a further ten major surgical errors in the past 12 months have emerged, as it was also revealed that a basic tool which has been proven to improve patient safety in operating theatres is not being consistently used in Lothian – despite being recommended by experts five years ago.
An internal NHS Lothian document passed to this newspaper by a whistleblower revealed that in the last year, the wrong body part had been operated on twice, and five swabs were left inside a single person following an operation while a needle was left inside a cardiac patient at the Royal Infirmary.
A series of cases in addition to the 12 major incidents highlighted, including appropriate equipment not being available to surgeons and theatre lists being incorrect which could have led to patients being harmed, have also been identified.
Labour Lothians MSP Sarah Boyack said it was now vital that changes were brought in as a matter of urgency. She added: “The cases uncovered by the Evening News highlight what can go wrong if proper checks aren’t in place.”
In 2008, the Scottish Patient Safety Programme recommended use of pre-surgery meetings and checklists to protect patients, but the document reveals that during August, briefings were completed just half of the time while checklists were not done in more than one in ten cases. Even when the measures were completed, investigators said they were not confident that they were always being done “consistently or appropriately”.
They are to become mandatory across NHS Lothian from January in response to the results of the investigation, despite staff raising concerns over the time they will take, with health bosses admitting that they could have prevented the serious errors.
Ms Boyack added: “Pre-operation safeguards have been considered best practice across the country for five years so serious questions have to be asked about why they are only now being officially implemented.
“Staff are telling health bosses that they don’t have time to carry out checks and this goes to the heart of the resource pressure being placed on the board.”
On the back of damning findings over safety in operating theatres, 1200 NHS Lothian staff are to be given training aimed at reducing human errors.
A spokesman for Healthcare Improvement Scotland confirmed that the pre-surgery briefings and checklist had been recommended since 2008. Further testing has led to the tool recently being included on a list of ten “safety essentials” to be used throughout Scotland.
He added: “People are only human and can make mistakes. Before surgery takes place we want to make sure that surgical teams have thought through everything that needs to be done to help keep patients safe.”
NHS Lothian’s medical director, Dr David Farquharson, admitted “all is not as it should have been” in relation to the 12 cases and said action had already been taken following a “rigorous investigation”.
He added: “We have implemented a number of processes, including the WHO surgical checklist. However, we are not satisfied that these are having the full impact across all our theatres and further actions are now being deployed to deliver further safety improvements.
“This priority work will be supported by additional staff training to improve the overall safety culture within our operating theatres.
“I would like to apologise again to the patients affected by these incidents and to reassure them and the public that full investigations have been carried out, or are ongoing, and that patient safety is always our top priority.”