An investigation has been conducted after surgeons at Wigan Infirmary operated on the wrong part of a patient.
NHS chiefs have confirmed that an action plan has been drawn up after the incident, relating to the dermatology department in November.
No further details have been revealed about the extent of the error but it has emerged that the blunder - classified as a ‘never event’ - is the fourth in 12 months for Wrightington, Wigan and Leigh NHS Foundation Trust.
One occurred earlier this year, another happened in October but has only just been reported as such to the trust’s quality and safety committee, and the fourth is said to have taken place in the December reporting period.
Further details are expected to be reported of the two latest breaches when WWL’s board meets again in January.
In a report to the quality and safety committee Steve Clancy, the trust’s divisional head of governance, with the assistance of the specialist services division, which is responsible for dermatology, said a "robust action plan" had been devised.
Trust chairman Robert Armstrong, who chairs the committee, and colleagues were told that "particular consideration would be given to patient flow and scheduling of lists, as these had been contributory factors to the incident."
Extra support was being offered to staff to help them through the incident, it was also reported,
Committee members are also said to have expressed concerns at the number of ‘never events’ - so-called because they should never occur in normal practice - across WWL this year, "particularly as a proportion of these were in relation to wrong site surgery".
Further reassurance was sought by the committee on local safety standards for invasive procedures before they meet again in
Referring to all four reported ‘never events’ Pauline Law, the trust’s nursing director, said in a performance report, also considered by the board: "Investigation teams are being established to look into these incidents and action plans will be developed thereafter."
One ‘never event’ was reported during the financial year 2016-17, involving a patient and bed rail entrapment, and external auditors were brought in to conduct a review.
The number of series reportable incidents in 2016-17 was also 31, compared to just 22 for 2015-16.