Blackpool patient given two injections in wrong eye

The trust that runs Blackpool Victoria Hospital requires improvement overall, the CQC says

A hospital patient was given two injections in the wrong eye after her surgeon became distracted and looked at another patient's scan by mistake.

While she ultimately "came to no harm", the incident at Blackpool Victoria Hospital's ophthalmology department was classed as a "never event".

Never events are defined by the NHS as wholly preventable serious incidents.

Meanwhile, a pneumonia patient had a needle inserted to relieve air pressure into the wrong side of their body.

The incidents emerged in a report to Blackpool Teaching Hospitals NHS Trust's board, highlighted by the Local Democracy Reporting Service.

The ophthalmology department previously came under scrutiny two years ago when it emerged that the wrong lens had been implanted into a patient's eye during a cataract operation.

Regarding the latest error, the report noted: "The lady had been receiving treatment to her left eye, which had been resolved.

"When the surgeon reviewed the scan of her right eye, he was interrupted and reviewed another patient's scan by mistake and referred the original patient for treatment which was not required.

"The patient came to no harm, but had to undergo two unnecessary injections, with the associated risks involved."

'Time critical'

Medical director Jim Gardner said: "We have reported untoward incidents in ophthalmology before and that has led to a review by the Royal College of Ophthalmology.

"We asked the ophthalmology department to bring a detailed action plan to executive which they did a couple of weeks ago, so we really make sure we are confident that our colleagues have learned lessons."

Discussing what had happened to the pneumonia patient in the Intensive Therapy Unit, Dr Gardner said: "The wrong side drain was very quickly spotted and put right and the team in critical care did a very thorough job of analysing what went wrong and learning from it."

The report said: "The patient had been turned over, however the clinician remained on the same side of the patient and proceeded to perform a needle compression on the left side, instead of the right side.

"This was a time critical procedure. The error was immediately recognised and the patient went on to have a needle compression performed on the correct side. This error resulted in the patient requiring a chest drain with its associated harm."

Dr Gardner added: "In both these never events the outcome for the patients was fine."

Earlier this year, the trust was ordered to improve its "inadequate" urgent and emergency care after inspectors from the Care Quality Commission found "risks to patients were not always recognised".

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