Surgeons in the United Kingdom mistakenly circumcised a man after the medical notes for the patient were switched with those of another person.
In a report by the National Health Service (NHS), doctors at University Hospital of Leicester (UHL) had unintentionally carried out a circumcision on a man last year.
The patient, who was left unidentified, was supposed to receive a cystoscopy, but his notes were mixed with those of another who was scheduled to be circumcised.
University Hospital Of Leicester Review
The report said the incident was only one of eight "never events" that happened at University Hospital of Leicester NHS Trusts over the past year.
The Leicester City Clinical Commissioning Group, who led the review of the hospital, said the workers also left a swab inside a child after the patient underwent nasal surgery.
There was also another incident involving patient receiving a medical procedure that was supposed to be for another patient. How did it happen? Both patients apparently had similar names.
The report also identified two separate cases in January and April last year where patients were mistakenly connected to air flowmeters instead of oxygen supplies.
In November, doctors accidentally implanted a hip nail on the wrong side of a patient.
Mistakes such as these have been a particular issue for the Clinical Commissioning Group (CCG).
"Failure to demonstrate learning from never events has been a concern for Leicester, Leicestershire and Rutland commissioners and partners for some time," the commission wrote in the report.
The CCG emphasized its role in helping the UHL NHS Trust to meet its quality and safety priorities. It intends to carry out this task through a comprehensive and collaborative method, as highlighted within its report.
The commission added that these objectives will be achieved by strengthening its relationships with medical institutions such as UHL. The CCG also needs to align its improvement strategy around a common set of clinical priorities.
The UHL NHS Trust said the never events mentioned in the report are serious and largely preventable. The hospital stressed that if the necessary preventive measures were to be made, then such safety incidents would not occur.
Leicester's Hospitals Safety and Risk Director Moira Durbridge apologized to patients involved in the incidents, adding that the hospital is determined to improve its services to its patients moving forward.
"We are committed to learning and improving and have enshrined this work into our clinical priorities within our Quality Strategy for 2019/20."
Other Incidents Of Medical Blunders
Of this number, 51 incidents involved surgeons operating on the wrong parts of patients' bodies, while 43 of them involved doctors accidentally leaving medical equipment inside of patients following a procedure.
About 24 cases had patients being given the wrong implant of prosthesis, and nine had the wrong tooth removed from them by mistake.
Government officials said the incidents are likely the result of hospital staff having been "overstretched and overworked," leaving patients to suffer from such mistakes.