NHS bosses could send out a nationwide product warning, after a surgical bungle at Great Western Hospital.
The Swindon hospital reported concerns to national NHS bosses over packs of surgical plate designed to hold together broken bones.
GWH directors said the composition of the pack handed to surgeons in the operating theatre made it hard for the doctors to distinguish which plate to fix to which fracture. The packs contained two plates, one for broken forearms and another for broken collarbones.
The hospital found seven occasions over the past 12 years where the wrong plate had been fitted to fractured bones. On one occasion a patient discovered to their shock the wrong plate had been fitted to their forearm as it gave way while they were using a rubber resistance band.
It was reported to NHS safety organisations and now Julie Marshman, GWH’s chief nurse, said the health service could soon be releasing a patient safety alert.
“It will say to every trust in England what has happened, this is a concern and they need to assure themselves they have looked at these areas,” she told GWH directors.
Dr Nicholas Bishop, a non-executive director at GWH, called the surgical plates “a hazard waiting to happen and we picked it up”.
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