A serviceman who went to the infirmary for a vesica medical terminate up getting circumcised by mistake .
The unknown patient role went in for a cystoscopy – a procedure to look inside the bladder using a sparse camera inclose through the urethra ( pee muddle ) – at a infirmary in Leicester , UK . Due to a mixup , which has been described as a " Never Event " , the humankind instead had his foreskin surgically removed from his phallus , theLeicester Mercury study .
This was one of eight " Never effect " that take on billet at hospitals go to the University Hospitals of Leicester NHS Trust in 2018 alone . A agent summons in this and several other mistake was a bankruptcy by the hospital to see from late Never result .
Never outcome are defined as " serious incidents that are wholly preventable " but happen anyway , despite all guidance and safety recommendation available at a national level that should have already been enforce by healthcare providers .
Other Never Events that took spot in Leicester last year include a man undergoing surgery intended for another humankind with a similar name . In MayandJune patients were given haywire - website radiology , where failure to learn from a former Never Event was listed as a contributory divisor .
“ loser to attest learning from never events has been a concern for Leicester , Leicestershire and Rutland commissioners and partners for some time , " the Leicester City Clinical Commissioning account said , accord to the Leicester Mercury .
In the case of the man who exit to the infirmary expecting a vesica examination and left without his prepuce , the computer error was reportedly due to a unproblematic paperwork mixup . The Trust decline to notice on individual case to the Leicester Mercury , but publish a worldwide assertion that they were " really dark to those patients involved , and of course of study we have in person apologised to each one . "
In an attempt to help medical practitioner memorize from previous Never event , the UK ’s National Health Service ( NHS ) print lists and definitions of Never issue . Between April 1 , 2018 , and January 31 , 2019 , 423 such event pass , accord to their figures .
These included :
A recurring theme seems to be down to the fact that human being are largely symmetrical , with wrong - side surgery get position over 20 times in this timeframe . Items being " retained post - procedure " was also a coarse job , with everything from plastic tubing to operative forceps and " part of a drill second " being left inside affected role .
There were also several incidents of people being given the wrong origin , and one slip of a patient having a transfusion that was intended for another patient .
