An investigation has been launched at a hospital after a patient had a tube inserted into the WRONG kidney.
The patient was undergoing an operation at the hospital’s radiology department to create an artificial opening in their kidney.
But the procedure, known as a nephrostomy, did not go to plan after the a tube, or stent, was inserted into the wrong kidney at Hull Royal Infirmary, East Yorks.
Hull and East Yorkshire Hospitals NHS Trust has now declared a “never event”, a serious incident that is wholly preventable if proper procedures are followed and has the potential to cause serious harm or even the death of a patient.
Executive chief nurse Mike Wright said: “A full apology has been provided to the patient.
“All of the staff have been spoken to within the department about the specifics of this and what they now need to do differently.
“They have been immediate changes and let’s hope we can avert further events in radiology.”
Two “never events” were declared at the trust last year after patients had operations on the wrong parts of their spines, sparking an investigation by the Royal College of Surgeons.
One mistake happened in the radiology department, when a vertebroplasty, used to relieve back pain caused by a spinal fracture, was carried out on the wrong part of a spine and, in the second case, a foreign locum doctor carried out surgery in the wrong place on a patient’s body after poor communication between the doctor and a consultant.
The board was told 113 “serious incidents” were declared by the trust in the past year, compared with 93 the year before.
Of the 20 serious incidents declared since the last board meeting, five involve delays in treatment, five relate to surgical or invasive procedures, three are delays in diagnosis and two involve patients falling.
The others relate to poor care of a deteriorating patient, a pressure ulcer, a retained dressing, consent not given for a procedure and one allegation of abuse.
A senior medic, known as a clinical fellow, was drafted in to review nine of the serious incidents over the past year relating to the poor care of patients whose health deteriorated. Staff on the wards and departments involved will now be working together to ensure the mistakes are rectified.
Mr Wright said: “These are good people who made human errors and we need to see why they don’t pick up the signs.”
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