Two NHS hospitals have placed posters within their operating theatres to remind surgeons and staff to check that they have the right patient before operating.

A spokesperson for The Oxford University Hospitals NHS Foundation Trust confirmed that they have introduced the posters in operating theatres at the John Radcliffe and Churchill hospitals following four incidents in which patients received the wrong operation throughout May to June this year.

Senior staff members at Oxford University Hospitals NHS Foundation Trust have apologised for these incidents, some of which have involved patients incorrectly receiving endoscopies, laser eye surgery, ovary removals or bowel examinations.

Medical director Tony Berendt said: "On behalf of those clinicians I would extend my apologies to all patients involved and our public for the inevitable impact on their confidence in our services that these kind of events lead to. We do take them extremely seriously."

These sorts of surgical mix-ups are are all ‘never events’, so called they are inexcusable errors which should never happen.

Surgical examples of ‘never events’ generally fall in to 3 main categories:

  1. Surgery at the wrong site - as in the examples here, when surgery is performed on the wrong part of the body (eg the wrong leg) or on the wrong patient;
  2. Incorrect placement of implant or prosthesis; and
  3. Retained foreign objects - where a item or instrument is accidentally left inside the patient after surgery.

Other examples of non-surgical ‘never events’ identified by NHS England include misapplication or incorrect dosages of medication, failure to take certain safety precautions for patients at risk of self-harm, misplacing of oro- or nso gastric tubes, and transfusion of an incompatible blood type.

Hospitals across England have seen 181 ‘never-events’ so far in 2018. Despite previous publicity and targeted attempts to reduce such incidents, there was no decline in number of ‘never events’ in England from 2016 to 2017, with 466 and 467 recorded respectively. Whilst the measure taken to remind surgeons in Oxford may seem amusing – perhaps these reminders to stop and think are exactly what is needed to address these human errors.

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Carolyn Lowe, Partner (Oxford/Milton Keynes) on 0186 578 1019 or

Siobhan Genever, Director (Nottingham) on 0845 271 6793 or

Karen Reynolds, Partner (Derby/Stoke) on 0845 272 5677 or

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