Surgeon removed wrong part of bowel after tattoo mix-up
Quick Look
- A cancer patient had the wrong part of their bowel removed due to a surgeon mistaking a tattoo for a tumor site.
- This is one of 10 "never events" reported by Betsi Cadwaladr University Health Board in North Wales, including other "wrong site" procedures and retained objects.
AI-generated summary
Why It Matters
A report for Betsi Cadwaladr University Health Board, which manages the NHS in north Wales, detailed 10 "never events" in the past 12 months. These included five "wrong site" procedures, two incorrect implants, two retained objects, and one medicine administered by the incorrect route.
A cancer patient had the wrong part of their bowel removed during an operation after a surgeon mistook a tattoo for the site of a tumour, a report has said.
It is one of 10 "never events" in the past 12 months, according to a report for Betsi Cadwaladr University Health Board, which manages the NHS in north Wales.
Five were listed as "wrong site" procedures, two involved incorrect implants, two involved retained objects such as swabs left inside patients, and one involved medicine administered by the incorrect route.
In one case, a surgeon at Bangor's Ysbyty Gwynedd located what was said to be a very visible tattoo or marking and operated assuming it indicated the site of the patient's tumour.
"This led the surgeon to take out the segment of bowel that did not have the cancer in it," said the report.
The patient has since had further investigations in preparation for further surgery.
A patient at Wrexham's Maelor Hospital attended a dermatology one-stop clinic after being referred through an Urgent Suspected Cancer clinical pathway, and underwent cryotherapy treatment in which cancer cells undergo extreme cold treatment.
The patient was also listed for a minor operation the same day and it was after that procedure they told the clinic nurse that the incorrect area had been treated so further surgery was carried out the same day.
The investigation into the incident is ongoing, said the report which is due to be considered at a meeting on Thursday.
What to Watch
AI outlook — possibilities, not facts
Further surgery will be required for the patient.
Very likely · Medium term
An investigation into the incident will conclude.
Very likely · Short term
Open Questions
- What is the current condition of the patient who had the wrong bowel segment removed?
- What are the specific findings of the ongoing investigation into the incident?
- What disciplinary actions, if any, will be taken against the surgeon involved?
- What measures are being implemented to prevent similar errors in the future?
