Two people were put at risk after Royal Derby staff forgot to take the guide wires out of tubes used for feeding patients through their noses.
It is not known how long the wires were mistakenly left in the patients or whether the patients left the hospital with them still in.
Both incidents occurred to two separate patients at Royal Derby Hospital on the same day – Friday, 5th April 2019.
Fortunately no harm was caused to the patients in the respective incidents.
The incidents involved nasogastric tubes (NG tubes) which are inserted through the nose to the oesophagus (gullet) into the stomach.
These are used for either feeding or drainage of excess stomach contents (fluid).
The NG tubes contain a guide wire inside them, which should be removed from the tube after the tube is inserted via the nose.
Failure to remove guide wires or improper insertion of the tube can result in serious harm or even death.
This is usually linked with food being incorrectly directed into the patient’s respiratory tract (breathing airway) instead of the stomach.
Now the organisation in charge of Royal Derby, the University Hospitals of Derby and Burton NHS Foundation Trust (UHDB), has introduced measures to prevent the “never events” happening again.
National guidance says that a “never event” is a “serious incident that is wholly preventable” due to stringent safety policies.
News of the repeat never events was published by the Derby and Derbyshire Clinical Commissioning Group in its July trust board report.
It reads: “Two never events were reported on the 05/04/19, both were relating to retained guide wires in nasogastric tubes.
“An action plan is in place which is being reviewed at the provider review meetings, with a member of nursing and quality team in attendance.
“The next meeting had been planned for September 2019, and interim updates will be provided by the Trust to the CCG.”
Cathy Winfield, executive chief nurse at UHDB, said: “The safety of patients in our care is always our main priority and it is important to stress that no patient was harmed as a result of the retained NG guide wire incidents.
“The trust identified the incidents in a timely manner and acted quickly to ensure no harm came to those involved.
“The trust has also introduced a number of measures and immediate actions to help ensure our staff follow the correct procedure.”