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Mid Staffordshire Foundation Trust

Mid Staffs nurses disciplined for string of cannula incidents


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.


Readers' comments (37)

  • It still sounds like it has learnt nothing.

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  • has this ever happened in another Trust?

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  • Is disciplining and suspension really the answer?

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  • It happens often, especially when the pressure on beds is intense, and patients are discharged in a hurry, often by the nurse in charge of the ward rather than the nurse who's patient it is.

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  • Anonymous | 2-Jun-2012 7:39 pm and yet it is still often the nurse whose patient it is who gets blamed for anything that is missed. There just isn't enough of us to cover and catch everything, when will those in charge realise that?

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  • Is the nurse suspended being used as an example for this high profile Trust to aim to show they are acting upon this incident?
    This smacks of blame.

    I've read for months all of the stories coming out of this Trust re-harm caused to patients/near misses. The culture there is clearly not one of learning, openness, justness and safety where nurses can learn from error by sharing and discussing incidents/concerns.

    I note the Trust found the culprits and 'disciplined' them. Yes, that made the rest of those bad nurses who send patients home ON PURPOSE (?) with cannulas insitu sit up and take notice!

    You feel you got it right this time Mid Staffs I'm sure...although, slight possibility of unsafe systems coming into play on your part methinks?

    Maybe a little more patient safety literature reading amongst the Mid Staffs team would be a good idea?

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  • Do patients have no responsibility for their own well being? If they are well enough to be discharged surely they must realise that it is not in their interest to go home with a cannula in their arm.
    I believe pressure of work to be an issue here also as no nurse would want to make this kind of avoidable error.

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  • what a load of bs At Healing Ealing many times people came into the A&E with cannulas still inplace we where told by management to remove them and not document that it was there.

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  • scapegoat comes to mind, poor nurses, who would want to work in that environment.

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  • No common theme exept lack of adequate staff ratios maybe?

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