Live COVID-19 Cases
  • World 179,697,906
    Confirmed: 179,697,906
    Active: 11,413,115
    Recovered: 164,393,444
    Death: 3,891,347
  • USA 34,420,284
    Confirmed: 34,420,284
    Active: 5,034,225
    Recovered: 28,768,542
    Death: 617,517
  • India 30,002,691
    Confirmed: 30,002,691
    Active: 662,304
    Recovered: 28,950,726
    Death: 389,661
  • Brazil 17,969,806
    Confirmed: 17,969,806
    Active: 1,178,597
    Recovered: 16,288,392
    Death: 502,817
  • France 5,760,002
    Confirmed: 5,760,002
    Active: 74,036
    Recovered: 5,575,137
    Death: 110,829
  • Russia 5,350,919
    Confirmed: 5,350,919
    Active: 331,122
    Recovered: 4,889,450
    Death: 130,347
  • UK 4,651,988
    Confirmed: 4,651,988
    Active: 217,498
    Recovered: 4,306,482
    Death: 128,008
  • Italy 4,254,294
    Confirmed: 4,254,294
    Active: 72,964
    Recovered: 4,054,008
    Death: 127,322
  • Spain 3,768,691
    Confirmed: 3,768,691
    Active: 123,122
    Recovered: 3,564,850
    Death: 80,719
  • Germany 3,730,774
    Confirmed: 3,730,774
    Active: 31,649
    Recovered: 3,608,100
    Death: 91,025
  • China 91,629
    Confirmed: 91,629
    Active: 512
    Recovered: 86,481
    Death: 4,636
Generic selectors
Exact matches only
Search in title
Search in content
Generic selectors
Exact matches only
Search in title
Search in content
homeless man on street waiting for vaccine

BY Leo Hynett


NHS Surgery Mixups

An NHS mixup leads to an invasive procedure being performed on the wrong patient.

JUNE 03  2021


A woman attended her gynaecology department for a fertility appointment and ended up receiving a colposcopy instead. Her name sounded similar to another patient with an appointment booked around the same time and, having thought her name was the one called out by a doctor, she ended up attending the wrong appointment and receiving the wrong procedure.

This latest mixup was ‘one of 472 serious healthcare incidents reported in England between 2019 and 2020’. The fact that these incidents are not unheard of – but thankfully infrequent – has raised questions about what can be done to support patients and staff with these mixups.


Never Events

The term ‘never events’ refers to the kind of event that should, quite simply, never happen. This is often used to refer to mistakes in surgeries with recent incidents including a piece of wire being left in after heart surgery. ‘Other never events included three dermatology procedures where patients had the wrong lesions or moles removed.’ In a cluster of never events at Royal Cornwall Hospital in Truro, they saw 8 occurrences between April and November last year.

The NHS is incredibly transparent about such events and the willingness to have these figures out in the open provides a high degree of accountability to the general public.

‘The NHS in England is one of the only healthcare systems in the world that is this open and transparent about patient safety incident reporting, particularly around Never Events. We are clear that we need to openly tackle these issues, not ignore them.’

The reporting of never events is not done to place blame but to examine why these failures occurred and how the event can be learned from. In a 2018 revision to the never events framework, the option to impose financial sanctions was removed as it reinforced the perception of a ‘blame culture’ within NHS Trusts.

Though it is unclear whether the mixup with the gynaecological procedure will be classed as a never event, this is still how it is being treated by the NHS. It is an opportunity to examine existing systems and consider how they may be improved.


Personal impacts of NHS mixups

The impacts of such mixups can be wide-reaching. ‘The Healthcare Safety Investigation Branch (HSIB) says such cases can lead to physical and psychological harm’ for the people at the centre of them.

Going into hospital for surgery, examinations, or treatments is already an anxious time for many and these kinds of mixups can lead to increased anxiety for those involved and for people reading about them. The woman involved in the gynaecology mixup decided ‘not to pursue fertility treatment’ following the distress she was caused. Mixups like these therefore impact the mental health of individuals involved as well as impacting the future of their care.

Following such distressing events, people may also become more reluctant to attend in future. In light of these impacts, it is vital that as much as possible is done to minimise the likelihood of these mixups occurring.


Supporting healthcare providers to prevent mixups

Emphasising the importance of learning from mixups as opposed to simply apportioning blame is vital in the handling of such events. It is important to consider why these incidents happen – is it an error in the system, such as calling up the wrong patient? Is it human error in reading which mole needs to be removed? If so, could the system be improved to make such errors harder to make?

It is important for providers to distinguish ‘between those [events] that should be prevented by human interactions and behaviours such as using checklists, counts and sign-in processes; and those that could be designed out entirely such as through the removal of equipment or introducing physical barriers to risks.’

This means that responsibility for errors – and for implementing improvements – lies not only with individuals but also the systems of routines they operate under. Any risk that can be designed out of a system removes (or at the very least minimises) the opportunity for human error.

Confusion in patient registration and mixups on the system can also lead to patients not being invited for screenings. This can also happen when systems are relied on to automatically issue invites based on gender markers, an issue recently flagged by a transgender doctor who struggled to organise his smear test. This is an indicator that fully automated systems may not be the solution either. Continuing to efficiently provide the correct care requires consistent improvement of systems of practice across the board.

It has been suggested that checking a patient’s NHS number could be a good way to ensure the right patient is being seen, but not everyone knows their number so this may prove difficult to implement. In the case of the gynaecology mixup, simply checking the name and date of birth once in the appointment could have been a good way to double-check the identity of the patient. Such things are normally only checked at check-in and there is evidently scope for mixups between a patient’s arrival and their appointment.



These ‘never events’ are rare and the NHS handles them very well after the fact. That said, the impact of these events on patients cannot be overstated. It is therefore vital that everything possible is done by the NHS as a whole and individual practitioners to avoid them.

NHS Trusts do not seek to point blame for these mixups, instead, they are using them as an opportunity to examine the root cause and flaws within their own systems. Through supporting their staff and ensuring they have the necessary tools available they aim to minimise the chances of these errors.


About the Author: Leo Hynett

Leo Hynett is a contributing Features Writer, with a particular interest in Culture, the Arts and LGBTQ+ Politics.

Recommended for you

How Can Employers Support Workplace Wellbeing?

Integrating wellbeing into business practices with the platform helping employees Thrive.