A PATIENT undergoing dental surgery to have a tooth removed had an extra one taken out by mistake, a report has revealed.
An investigation has been started into the blunder at Queen Alexandra Hospital in Cosham which happened over the summer.
It came to light in a report to directors and is classed a so-called never event. These are serious but 'extremely rare’ incidents.
Any investigation into such events examines what went wrong and makes recommendations to prevent them in the future.
'One never event reported in August involved removal of an additional tooth,’ a Portsmouth Hospitals NHS Trust integrated performance report said.
‘An investigation has commenced, initial learning points include use of the WHO checklist for procedures under local anaesthetic, reconfirmation of consent and use of the whiteboard for all procedures.’
No detail about the patient has been revealed by the health trust.
Another incident in August ‘involved a retained piece of equipment following a surgical procedure’ – thought to have been a piece of equipment left in a patient’s body.
A never event in September saw a patient receive a prosthesis ‘with two parts which are potentially incompatible’.
Board papers said: ‘Investigations have commenced into both events.
‘Initial learning points include storage of prostheses in theatre, checking processes and surgical count processes.’
John Knighton, medical director at Portsmouth Hospitals NHS Trust, said: ‘Our priority is always the care and safety of our patients. Never events are extremely rare and we take any incident very seriously.
‘Once we are alerted to the possibility of a never event, a robust process is undertaken to understand fully what has happened and to support the patient and their family appropriately.
‘These cases are presented at our Trust Incident Review panel meetings where a plan for any immediate actions are agreed along with the appropriate method of investigating the incident are.
‘The investigation aims to identify any issues and strengthen learning to improve safety processes and help prevent similar events from happening in the future.’