Surgeons have mistakenly operated on the wrong part of patients’ bodies 13 times in public hospitals since 2020, while similar calamities were narrowly averted on 28 occasions, new records have revealed.
The ‘wrong-site’ incidents occurred at six HSE-run hospitals, where doctors operated on incorrect arms, legs, vertebrae, elbows, hands, and eyes, causing unintended harm to their patients.
Five such incidents have already been reported this year – the highest number since 2019. They occurred at Connolly Hospital Blanchardstown, Cork University Hospital, Sligo University Hospital, University Hospital Limerick, and Midland Regional Hospital in Tullamore.
Meanwhile, 28 ‘near-misses’ were reported at 10 hospitals, nine of which occurred at Our Lady’s Hospital in Navan.
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The HSE describes a ‘near miss’ as an incident that was prevented from occurring by chance or by timely intervention, without which unintended injury or harm could have been caused to a patient.
A total of five near misses have been recorded to date this year in Dublin, Cork, Kerry, Waterford and Wexford. Last year, 13 were reported in seven hospitals, and nine occurred at four hospitals in 2021.
Wrong-site incidents can have catastrophic consequences and resulted in the removal of a boy’s healthy left kidney instead of his poorly functioning right kidney at Our Lady’s Children’s Hospital in 2008.
Earlier this year, a surgeon mistakenly performed a procedure on a patient’s opposite eye, while another performed surgery on the wrong hand. Other incidents involved wrong-site surgery on patients’ hips, legs and fingers.
In 2020, a patient had surgery on an incorrect vertebra in their lower back. The following year, doctors mistakenly operated on the wrong ankle, arm and elbow in separate incidents.
The data covers the period from the beginning of 2020 to September 18, 2023, and was released by the HSE under freedom of information laws.
It relates specifically to category 1A Serious Reportable Events, which is defined as surgery on the wrong body part by a healthcare service provider. The figures exclude voluntary hospitals.
However, a HSE spokesman said not all of the documented incidents had occurred in a surgical theatre, and also included radiology and incidents that took place on hospital wards.
“It is HSE policy that all incidents are identified, reported and reviewed so that learning from events can be shared to improve the quality and safety of services,” he said.
“The HSE has in place systems and processes to identify, report, investigate, manage and address incidents that arise during the course of delivering healthcare to patients.
“Services also place emphasis on the importance of anticipating from experience and knowledge, the types of incidents that are likely to occur in their service area. In line with the HSE’s Integrated Risk Management Policy and Guidance documents services are continually engaged towards identifying areas where incidents are likely to occur and putting in place systems to prevent or reduce the likelihood of the risk of their occurrence.”
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