A TOTAL of 12 serious incidents requiring investigation (SIRIs) were reported to hospital bosses over the course of May, including one in which a patient received an insulin overdose.
Papers seen by the board at Oxford University Hospitals NHS Foundation Trust drew attention to the ‘never event’, classed as an error that had the potential to cause serious patient harm or death and that should never happen.
The incident took place in the children’s and women’s division and involved a patient who was critically ill following childbirth.
Addressing the board yesterday, medical director Dr Tony Berendt said: “This was an insulin maladministration event, where a member of staff used an incorrect syringe to draw up insulin.
“Despite going through checks with two staff members they managed to administer an overdose.
“I’m pleased to report the patient came to no harm but it caused significant anxiety.”
Other SIRIs declared over the course of May included pressure sores, a failure to identify a patient’s fractured ribs and a missed diagnosis following imaging.
A SIRIs must be investigated to ensure the same error does not take place again.
OUH has more than a million patient contacts a year and receives about 1,000 complaints from members of the public over that period.
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