MEDICAL NEGLIGENCE PATIENT SAFETY 1.2A

UNDEFINED NOTIFIABLE INCIDENT WRONG SITE SURGERY

John Whelan with Specialist expertise in medical negligence and Patient Safety gives an example of a case which falls outside of the definition of a Notifiable Incident as envisaged by item 1.2 of the Patient Safety Act 2023.      This example involves similar mistakes to that envisaged by item 1.2 of the Act but yet since it doesn’t lead to the death of the Patient it is not a Notifiable Incident as defined by Item 1.2

This example is one of many cases which should fall within the ambit of the Patient Safety Act and can be introduced by Ministerial Regulation under Section 8.

There are 13 notifiable incidents set out in the Act but other notifiable incidents may be introduced by Ministerial Regulation under Section 8 of the Act.

An example of a case where a person with diabetes was admitted to hospital for the amputation of their infected leg, but the amputation that took place was in fact the Patient’s healthy leg.

An example of a Notifiable Incident involving wrong site surgery on the Patient (but not resulting in death) could be.

Incident description:   A male Patient with poorly controlled diabetes is admitted to the hospital for the scheduled amputation of his infected left leg due to severe diabetic ulcers and gangrene.

The Patient had a history of peripheral neuropathy and poor circulation which made the infection in his leg life threatening.

A surgical amputation is required to prevent the spread of infection.

However, during the pre operative process, the wrong leg, “the healthy right leg” is marked for amputation due to a series of mistakes.   

1. The medical records were not properly verified.
2. The surgeon misinterpreted the nursing notes during the briefing.
3. The surgical team failed to perform a time out procedure to double check the Patient’s condition and the surgical site before the operation.
4. As a result, the Patients healthy right leg is amputated. The mistake is only discovered post operatively when the surgical team reviews the Patients notes and realises that the left leg, the one that was infected remains intact. 
5. The consequences for the Patient are devastating, they now face the prospect of losing both legs with one amputated unnecessarily and the other still needing removal due to infection.

For more detailed insights into how the Patient Safety Act 2023 impacts you and how Whelan Law can support you, please visit our Patient Safety Rights Legal Advice https://www.whelanlaw.ie/news/medical-negligence-and-patient-safety/