Labelling gaffe saw KGH patient given eye injection - based on another person's scans

It's the second 'never event' in the hospital's ophthalmology department in three months

By Sam Wildman
Wednesday, 4th August 2021, 10:25 am
An investigation is under way at KGH.
An investigation is under way at KGH.

A blunder at Kettering General Hospital saw a patient given an eye injection - based on another person's scans which were wrongly labelled with their details.

An investigation is taking place at the Rothwell Road hospital after the second 'never event', the kind of medical mistake that should never happen, in the space of just three months in the ophthalmology department.

The Northants Telegraph previously reported that a mix-up in April saw a patient given a Lucentis injection into their wrong eye.

Sign up to our daily newsletter

And it's now been revealed that a second serious mistake took place in June when an intravitreal (inside the eye) injection was given to a patient, listed as patient A.

They were given the injection based on the scans of another patient, listed as patient B, which were inadvertently labelled with patient A's demographic details.

Thankfully no harm was caused to patient A who - fortunately - actually saw their visual acuity improve as a consequence of the injection.

Now a new system has been put in place and a trust review will be conducted to review all imaging practices and ensure patients and imaging are linked.

Kettering General Hospital’s interim medical director, Rabia Imtiaz, said: “Two unrelated ‘never events’ occurred in ophthalmology during 2021.

"Neither case resulted in harm to the patients involved.

“Both incidents, which were due to human error, are being investigated in line with national protocols, and appropriate measures have been taken to reduce the risk of these highly unusual errors happening again.

"We treat all ‘never events’ in line with national good practice, and work closely with the patients concerned to address any concerns.”

The interim medical director also visited the area to review processes and seek assurance about checking procedures.

The June incident was KGH' s third 'never event' of 2021, with the first taking place in February.

In that incident a patient disconnected his prescribed oxygen tubing from the wall oxygen flow meter and connected to a portable cylinder but that, on returning to his bed, inadvertently connected the oxygen tubing to the medical air flow meter. They said that when identified this was immediately rectified and the patient's oxygen levels returned to within his expected range. The patient subsequently died but the hospital said the incident was not deemed to have contributed. They said immediate actions were taken to ensure air points are capped and all staff were reminded to not allow patients to connect and reconnect oxygen.

Prior to February the last 'never event' at KGH was in November 2019, although details of the incident were not made public.