Chamber and committees

There is no comprehensive list of diagnoses available which can reliably identify all surgical errors. The table below shows the number of cases recorded in Scotland where a diagnosis of surgical error can be inferred using available information.

Acute NHS hospital (non-obstetric, non-psychiatric) inpatient/day case discharges; number of hospital episodes¹ with a diagnosis of surgical error², years ending 31 March 2004 to 2008.

NHS Board of Residence	2004	2005	2006	2007	2008
All areas	1,050	1,169	1,100	1,039	1,156
Ayrshire and Arran	90	88	104	81	70
Borders	20	19	12	25	10
Dumfries and Galloway	83	103	71	79	83
Fife	126	142	143	123	192
Forth Valley	53	39	26	49	35
Grampian	86	119	119	125	104
Greater Glasgow and Clyde	213	223	194	126	192
Highland	67	75	88	79	86
Lanarkshire	32	69	58	48	68
Lothian	235	246	228	227	254
Tayside	30	25	37	51	39
Island boards3	7	15	16	22	18
Other4	8	6	4	4	5

Source: SMR01 acute hospital inpatient and day case discharges.

Notes:

1. May include multiple episodes for the same patient.

2. Cases have been selected using the International Classification of Diseases 10th revision. (ICD10) codes:

Y60.0 - Unintentional cut, puncture, perforation or haemorrhage during surgical operation.

Y61.0 - Foreign body accidentally left in body during surgical operation.

Y62.0 - Failure of sterile precautions during surgical operations.

Y65.2 - Failure in suture or ligature during surgical operations.

Y65.5 - Performance of inappropriate operation.

T81.2 - Accidental puncture and laceration during procedure not elsewhere classified.

T81.5 - Foreign body accidentally left in body cavity or operation wound following a procedure.

Acute hospital discharge summaries can record up to six diagnoses for each episode, a main diagnosis and up to five additional or supplementary diagnoses. All six positions have been examined to produce the figures shown in the table.

3. Comprises Orkney, Shetland and Western Isles NHS boards.

4. Outwith Scotland and not known.

The information requested is not held centrally.

The information requested is shown in the table below.

Acute hospital (non-obstetric, non-psychiatric) inpatient/day case discharges; number of patients¹ with a diagnosis of unintentional cut, puncture, perforation or haemorrhage² during surgical operations, years ending 31 March 2004 to 2008.

NHS Board of Residence	2004	2005	2006	2007	2008
All areas	625	640	602	605	634
Ayrshire and Arran	54	49	67	53	44
Borders	12	10	10	15	4
Dumfries and Galloway	44	49	42	42	38
Fife	85	90	85	80	88
Forth Valley	25	18	13	23	18
Grampian	59	72	71	68	64
Greater Glasgow and Clyde	107	98	82	69	94
Highland	42	45	44	49	54
Lanarkshire	21	35	24	26	42
Lothian	143	144	129	136	151
Tayside	21	19	25	31	19
Island boards3	6	9	8	10	15
Other4	6	2	2	3	3

Source: SMR01 acute hospital inpatient and day case discharges.

Notes:

1. Individual patients are only counted once within any given year. Patients may be counted more than once across years.

2. Cases have been selected using the International Classification of Diseases 10th revision.

(ICD10) codes:

Y60.0 - Unintentional cut, puncture, perforation or haemorrhage during surgical operation.

T81.2 - Accidental puncture and laceration during procedure not elsewhere classified.

Acute hospital discharge summaries can record up to six diagnoses for each episode, a main diagnosis and up to five additional or supplementary diagnoses. All six positions have been examined to produce the figures shown in the table.

3. Comprises Orkney, Shetland and Western Isles NHS boards.

4. Outwith Scotland and not known.

The five NHS wheelchair centres in Scotland are planning a pilot service development that will trial new powered wheelchair equipment. People who may wish to participate in this pilot will be identified through the usual health and social care referral process for NHS wheelchair provision.

The numbers of deaths where anaphylactic shock was a contributory factor, and where this followed an adverse reaction to a drug or medicine, are shown in the following tables. The International Classification of Diseases (ICD) rules do not allow anaphylactic shock to be counted as the underlying cause of death. Therefore, table 1 shows numbers of deaths where anaphylactic shock was a contributory factor to the death; table 2 shows numbers of deaths for which a contributory factor was anaphylactic shock due to adverse effect of correct drug or medicine properly administered.

Table 1: Deaths Where Anaphylactic Shock Was a Contributory Factor by NHS Board And Year.

NHS Board	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
Ayrshire and Arran	0	1	0	0	0	0	0	0	0	0
Borders	0	0	1	0	0	0	0	0	0	0
Dumfries and Galloway	0	0	0	0	0	0	0	0	0	0
Fife	0	0	0	0	0	0	1	0	1	0
Forth Valley	0	0	0	0	0	0	0	0	0	0
Grampian	0	0	0	1	0	1	0	0	0	0
Greater Glasgow and Clyde	0	1	0	0	1	0	0	1	2	2
Highland	0	0	0	0	0	0	0	0	1	0
Lanarkshire	0	0	0	0	0	0	0	0	0	0
Lothian	0	0	0	0	0	0	1	0	0	0
Orkney	0	0	0	0	0	1	0	0	0	0
Shetland	0	0	0	0	0	0	0	0	0	0
Tayside	0	0	0	0	0	0	0	0	0	0
Western Isles	0	0	0	0	0	0	0	0	0	0
Scotland	0	2	1	1	1	2	2	1	4	2

Table 2: Deaths Where Anaphylactic Shock Was a Contributory Factor Due to the Adverse Effects of a Prescribed Drug or Medicine Properly Administered, by NHS Board And Year.

NHS Board	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
Ayrshire and Arran	0	1	0	0	0	0	0	0	0	0
Borders	0	0	1	0	0	0	0	0	0	0
Dumfries and Galloway	0	0	0	0	0	0	0	0	0	0
Fife	0	0	0	0	0	0	1	0	0	0
Forth Valley	0	0	0	0	0	0	0	0	0	0
Grampian	0	0	0	1	0	0	0	0	0	0
Greater Glasgow and Clyde	0	1	0	0	1	0	0	1	1	0
Highland	0	0	0	0	0	0	0	0	0	0
Lanarkshire	0	0	0	0	0	0	0	0	0	0
Lothian	0	0	0	0	0	0	1	0	0	0
Orkney	0	0	0	0	0	1	0	0	0	0
Shetland	0	0	0	0	0	0	0	0	0	0
Tayside	0	0	0	0	0	0	0	0	0	0
Western Isles	0	0	0	0	0	0	0	0	0	0
Scotland	0	2	1	1	1	1	2	1	1	0

Source: General Registry Office Scotland.

Table 1. Deaths where the Underlying Cause was the Adverse Effects of Drugs and Medicines in Therapeutic Use - by NHS Board Area and Year

NHS Board	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
Ayrshire and Arran	4	1	3	1	2	1	1	2	3	0
Borders	0	0	0	0	3	1	0	2	2	1
Dumfries and Galloway	1	0	0	1	0	0	3	1	1	0
Fife	2	4	4	0	0	0	2	1	3	1
Forth Valley	2	1	1	0	2	2	3	0	2	2
Grampian	4	1	4	1	0	4	3	3	1	5
Greater Glasgow and Clyde	4	6	8	6	3	2	6	4	4	5
Highland	2	2	2	2	3	1	3	0	0	1
Lanarkshire	1	1	0	2	3	2	0	6	5	1
Lothian	2	5	5	8	4	4	4	2	3	3
Orkney	1	0	0	0	0	1	0	1	0	0
Shetland	1	0	1	0	0	1	0	0	0	0
Tayside	2	4	1	5	4	1	1	2	0	3
Western Isles	0	1	0	0	0	0	0	0	0	0
Scotland	26	26	29	26	24	20	26	24	24	22

Source: General Registry Office Scotland. The figures given are the numbers of deaths coded for the adverse effects of drugs and medicines in therapeutic use. These figures do not include deaths involving drugs and medicines in other ways, for example deaths caused by drug abuse, accidental poisoning, or intentional self-poisoning. Figures for 2008 are provisional.

Information on the number of people admitted to NHS hospitals in Scotland with a diagnosis of anaphylactic shock following an adverse reaction to drugs or medicine in each of the last 10 financial years is shown in the following table.

Table 1. People Admitted to NHS Hospitals in Scotland with a Main Diagnosis of Anaphylactic Shock Following an Adverse Reaction to Drugs or Medicine, Financial Years Ending 31 March

NHS Board of Treatment	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
Ayrshire and Arran	4	5	6	4	6	2	6	3	4	4
Borders	1	-	-	-	1	-	-	1	-	-
Dumfries and Galloway	3	2	2	-	-	3	-	1	2	2
Fife	3	4	3	2	1	1	3	4	3	4
Forth Valley	-	3	3	3	2	4	8	2	2	5
Grampian	7	4	4	3	5	5	5	5	8	6
Greater Glasgow and Clyde	10	12	9	14	18	8	17	12	8	19
Highland	3	1	-	3	2	1	5	5	1	4
Lanarkshire	5	-	2	-	2	1	2	1	-	1
Lothian	13	8	11	9	6	7	10	6	3	11
Orkney	-	-	-	1	-	-	-	-	-	-
Shetland	-	-	-	1	-	-	1	-	1	2
Tayside	-	1	6	6	1	7	5	4	4	5
Western Isles	-	-	-	-	-	-	-	-	-	-
NHS Scotland	49	40	46	46	44	39	62	44	36	63

Source: Information Services Division (ISD) Scotland. - indicates zero cases.

Information on the number of people admitted to NHS hospitals in Scotland with a main diagnosis of anaphylactic shock in each of the last 10 financial years is shown in the following table.

Table 1. People Admitted to NHS Hospitals in Scotland with a Main Diagnosis of Anaphylactic Shock, Financial Years Ending 31 March

NHS Board of Treatment	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
Ayrshire and Arran	14	22	18	23	30	14	26	30	38	30
Borders	6	13	10	6	7	4	17	16	17	14
Dumfries and Galloway	7	4	6	3	2	9	3	10	6	14
Fife	9	14	13	16	8	9	23	22	29	16
Forth Valley	5	17	14	17	16	19	31	14	15	32
Grampian	28	20	22	25	38	38	33	46	40	55
Greater Glasgow and Clyde	53	66	69	75	75	57	71	86	93	123
Highland	20	9	14	14	20	27	35	37	27	24
Lanarkshire	14	15	14	18	23	19	25	33	19	17
Lothian	57	51	64	61	55	41	57	55	62	78
Orkney	-	1	1	2	1	1	1	-	-	-
Shetland	1	1	3	3	2	1	2	2	2	6
Tayside	25	34	39	35	21	28	24	29	38	27
Western Isles	-	-	-	1	-	6	7	7	8	3
NHS Scotland	239	267	287	299	298	273	355	387	394	439

Source: Information Services Division (ISD) Scotland. “ indicates zero cases.

Between 1999 and 2008 there was only one death in persons aged 17 or under, where the underlying cause was adverse effects of drugs and medicines in therapeutic use. This occurred in 1999 in the Grampian NHS board area.

The following tables show the number of patients in acute hospitals with a diagnosis of mental and behavioural disorders related to alcohol use, by health board of treatment and by age group.

Table 1. Number of People Aged 13 and Under Admitted to Hospital with Mental and Behavioural Disorders Associated with Alcohol Use, by Health Board of Treatment and by Year^1-6

NHS Board	2003-04	2004-05	2005-06	2006-07	2007-08
Ayrshire and Arran	20	28	18	26	18
Borders	12	*	*	*	*
Dumfries and Galloway	*	*	*	*	*
Fife	*	*	*	*	*
Forth Valley	13	*	10	10	*
Grampian	10	*	*	*	*
Greater Glasgow	21	32	24	35	31
Highland	*	*	*	14	10
Lanarkshire	*	10	12	*	10
Lothian	17	15	13	19	12
Orkney	*	*	-	-	-
Shetland	*	*	*	*	-
Tayside	*	11	13	10	10
Western Isles	*	*	*	*	*
Scotland	127	130	127	148	133

Table 2. Number of People Aged 14 to 17 Years Admitted to Hospital with Mental and Behavioural Disorders Associated with Alcohol use, by Health Board of Treatment and by Year^1-6

NHS Board	2003-04	2004-05	2005-06	2006-07	2007-08
Ayrshire and Arran	135	132	105	117	130
Borders	38	16	35	41	41
Dumfries and Galloway	11	14	12	14	29
Fife	14	18	30	33	26
Forth Valley	30	17	12	20	15
Grampian	76	56	76	79	80
Greater Glasgow	116	155	146	166	150
Highland	69	58	61	65	79
Lanarkshire	56	58	50	51	69
Lothian	54	42	64	84	88
Orkney	*	*	*	*	*
Shetland	*	*	*	*	*
Tayside	64	56	53	47	48
Western Isles	21	17	15	15	11
Scotland	700	655	673	743	778

Table 3. Number of People Aged 18 Years or Over Admitted to Hospital with Mental and Behavioural Disorders Associated with Alcohol Use, by Health Board of Treatment and by Year^1-6

NHS Board	2003-04	2004-05	2005-06	2006-07	2007-08
Ayrshire and Arran	1,901	1,911	1,761	1,858	1,963
Borders	306	329	312	414	419
Dumfries and Galloway	346	324	341	336	335
Fife	605	695	708	763	745
Forth Valley	664	732	512	616	690
Grampian	1,579	1,599	1,518	1,693	1,912
Greater Glasgow	6,196	6,672	6,560	6,935	7,093
Highland	1,502	1,357	1,388	1,351	1,447
Lanarkshire	1,794	1,842	1,710	1,775	1,863
Lothian	2,162	2,217	2,267	2,619	2,743
Orkney	102	97	94	105	125
Shetland	70	78	90	83	82
Tayside	1,106	1,100	1,062	1,035	1,078
Western Isles	263	219	216	212	172
Scotland	18,393	18,979	18,343	19,594	20,433

Source: Information Services Division (ISD) Scotland.

Notes:

*Numbers have not been shown where these are potentially disclosive.

1. The totals for the number of people admitted in each health board may not match the Scotland totals; an individual is counted only once in the Scotland total but may appear in more than one health board of treatment.

2. Excludes psychiatric hospital units and maternity hospitals. Transfers have also been excluded.

3. Caution is necessary when interpreting these figures, as the recording of alcohol misuse may vary from hospital to hospital; where alcohol misuse is suspected but unconfirmed it may not be recorded by the hospital.

4. Diseases recorded using the International Classification of Diseases 10th Revision (ICD10); mental and behavioural disorders associated with alcohol use: F10.

5. Up to six diagnosis codes can be recorded. All six diagnostic positions have been used when classifying patients with the diagnosis.

6. Figures in the table only relate to those individuals who are treated as inpatients and do not include individuals managed as outpatients or individuals attending accident and emergency who are not subsequently admitted.

7. Data for 2003-04 to 2007-08 is based on revised alcohol codings; data for 2007-08 is provisional.