Nurses at Mid Staffordshire Foundation Trust have been disciplined with one suspended after the trust revealed a patient had been discharged with a cannula left in their arm.
The trust has declared the incident, which happened in early April, as a local “never event”.
However, it is the latest in a string of similar incidents and takes the total number of cannulas left in situ to 16 over the 12 month period since April 2011.
After investigating some of the incidents the trust found a discharge checklist completed by nurses in several of the incidents had been ticked to say the cannula had been removed when it had not.
As a result the trust has told Nursing Times it has disciplined nurses involved with each nurse receiving a note in their file. One nurse has been suspended.
In the latest incident the unidentified patient was discharged from ward 11 at the hospital, which is at the centre of a public inquiry by Robert Francis QC, with the IV cannula still in place. It was later removed by the district nursing service.
Colin Ovington, director of nursing and midwifery at Mid Staffordshire NHS Foundation Trust, said: “It is totally unacceptable for cannulas to be left in when patients are discharged – and we have stressed the importance of staff taking responsibility for their own practice and the comfort and safety of patients.
“We have introduced a double checking policy relating to cannulas/patients being discharged. This includes a requirement for staff to undertake a visual check of the patient’s arms and hands for the presence of cannulas and a signature of two nurses to confirm this has been done.
“We are determined that this elementary error will be eradicated and to that end several nursing staff have been disciplined for errors relating to cannulas.”
In addition to the visual check posters have been placed around the hospital wards, departments and corridors to help raise awareness of the issue and the trust has met with the PCT to review the root cause analysis of all the retained cannula incidents from the last year.
Actions agreed include ensuring the Visual Infusion Phlebitis score tool is fully implemented, additional training for non-registered staff, and a final check on patients will be carried out in the discharge lounge on top of the double check when the patient leaves the ward.
A route cause analysis on each case has been carried out but the trust has found no common theme.
Information supplied to HSJ