‘Wrong eye' laser op halted at Shropshire hospital, says report
A serious medical event involving a 'wrong eye' laser happened at the trust running Shropshire's two main hospitals in December, it has been revealed.
The incident recorded by the Shrewsbury and Telford Hospital NHS Trust (SaTH) is currently being investigated and at this stage is being treated as a 'possible never event'.
Four other never events – which are named so because they are incidents that guidelines say should never happen – were recorded by the trust last year.
A report to SaTH's trust board, which meets tomorrow, says a patient was booked for Panretinal Photocoagulation (PRP), a type of laser treatment for the eye.
The report said: "Patient booked for outpatients left eye retinal PRP indirect laser.
"Patient was consented and agreed for left eye retinal laser.
Preparation
"The left eye was prepared with anaesthetic drops in preparation for the laser specific contact lens application.
"The contact lens was placed on the right eye and a few laser spots applied, before the procedure was halted.
"While there is evidence to suggest this may not be a never event, at the request of the commissioners this has been identified as such until the investigation is completed at which time evidence one way or another may be submitted to suggest the appropriate classification."
In June last year, a never event happened in an operating theatre at Telford’s Princess Royal Hospital.
It involved a “retained swab” during an ear, nose and throat procedure, but the trust said no harm was caused to the patient.
A never event recorded by the trust in May involved "wrong site" surgery.
A never event recorded in February last year was to do with the administration of oramorph – a medication that should be taken orally but was given through the IV route.
