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News Article
Patient had wrong eye injected after software error
Patient Safety Learning posted a news article in News
Herefordshire clinicians injected a patient in the wrong eye after a technical blunder, board papers have revealed. The Wye Valley Trust patient was injected with an antivascular endothelial growth factor to treat age-related macular degeneration. They did not come to harm as a result of the incident. The mistake occurred after the ophthalmology department deleted a poor quality image of one of the patient’s eyes. This shifted up the other images, which were stored sequentially using software called IMAGEnet6, which led to the mistake. Although initially reported as a “never event,” the incident was downgraded to a “serious incident” after a review by the Herefordshire Clinical Commissioning Group (CCG). The trust, which is still using the software, is updating its standard operating procedure and has installed new technology that can take higher quality images. A spokesman said: “Patient safety is the trust’s priority. While no harm was caused to this patient, the trust has taken this incident seriously.” Read full story (paywalled) Source: HSJ, 21 January 2020- Posted
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- Medicine - Ophthalmology
- Imaging
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Content ArticleThe Care Quality Commission (CQC)’s annual report on Ionising Radiation (Medical Exposure) Regulations in England has been published. The report gives a breakdown of the number and type of statutory notifications of errors received from healthcare providers in 2018/19 where patients were exposed to ionising radiation. These notifications are where there have been significant accidental or unintended exposures, for example where a patient received a higher dose than intended or where the wrong patient was exposed.
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Content ArticleThis is a story of a patient in whom the emergency department missed the same diagnosis twice, four years apart. The first occasion (prior to his diagnosis of ankylosing spondylitis) was understandable. The second was not. As a result of this case, the hospital have changed their x-ray policy for non-traumatic back pain. They also want to share key learning points (the majority of which were due to lack of awareness about a relatively rare condition and its complications) as widely as possible, to help others avoid the same errors. This reflective learning features guest educator, Mr Gareth Dwyer (the patient).
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- Accident and Emergency
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