A man who went to the hospital for a bladder checkup ended up getting circumcised by mistake.
The unnamed patient went in for a cystoscopy – a procedure to look inside the bladder using a thin camera inserted through the urethra (pee hole) – at a hospital in Leicester, UK. Due to a mixup, which has been described as a "Never Event", the man instead had his foreskin surgically removed from his penis, the Leicester Mercury reports.
This was one of eight "Never Events" that took place at hospitals belonging to the University Hospitals of Leicester NHS Trust in 2018 alone. A factor cited in this and several other mistakes was a failure by the hospitals to learn from previous Never Events.
Never Events are defined as "serious incidents that are wholly preventable" but happen anyway, despite all guidance and safety recommendations available at a national level that should have already been implemented by healthcare providers.
Other Never Events that took place in Leicester last year include a man undergoing surgery intended for another man with a similar name. In May and June patients were given wrong-site radiology, where failure to learn from a previous Never Event was listed as a contributory factor.
“Failure to demonstrate learning from never events has been a concern for Leicester, Leicestershire and Rutland commissioners and partners for some time," the Leicester City Clinical Commissioning report said, according to the Leicester Mercury.
In the case of the man who went to the hospital expecting a bladder examination and left without his foreskin, the error was reportedly due to a simple paperwork mixup. The Trust declined to comment on individual cases to the Leicester Mercury, but issued a general statement that they were "genuinely sorry to those patients involved, and of course we have personally apologised to each one."
In an attempt to help medical practitioners learn from previous Never Events, the UK's National Health Service (NHS) publishes lists and definitions of Never Events. Between April 1, 2018, and January 31, 2019, 423 such events occurred, according to their figures.
- Botox injections being given to a patient instead of nerve block
- Laser surgery being performed on the wrong eye
- Ovaries being removed in error when the plan was to preserve them
- A patient receiving a colonoscopy that was intended for another patient
A recurring theme seems to be down to the fact that humans are largely symmetrical, with wrong-side surgery taking place over 20 times in this timeframe. Items being "retained post-procedure" was also a common problem, with everything from plastic tubing to surgical forceps and "part of a drill bit" being left inside patients.
There were also several incidents of people being given the wrong blood, and one case of a patient having a transfusion that was intended for another patient.