Leeds hospital errors report includes patient overdose

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a swab being left inside a patient and another being given a medication overdose were among serious incidents in Leeds hospitals in the first two months of the year.

A total of 18 incidents were reported by Leeds Teaching Hospitals NHS Trust.

Most of these were pressure ulcers, the board of directors was told. Another involved a medication error, one a delayed report and in another there was a failure to arrange a follow-up test.

In a report, trust chief medical officer Dr Yvette Oade said findings from investigations into these incidents were shared with the patient or their family.

She asked the board to “be assured that actions are being taken to address the key risk areas identified from serious incidents.”

Hospital bosses are publishing their regular reports on serious incidents for the first time.

In January and February there were 18, 14 of which involved pressure ulcers.

Dr Oade said reducing the number of pressure ulcers had been a priority goal for improvement during the last two years.

One of the other incidents involved a patient inadvertently being given an overdose of Propofol, an anaesthetic drug, in the Emergency Department.

“No serious harm was caused to the patient who was being treated appropriately,” the report said, adding that lessons had been learned.

During an operation on another patient to the site of a pacemaker, a swab was found which had been left inside their body from a previous procedure.

This led to a safety alert being issued to highlight procedures and actions to prevent it reoccurring.

There was also a delay to a report being issued from the radiology department following a routine CT Scan.

“The delay in diagnosis is likely to affect the patients long-term outcome,” the report said.

In another incident, a patient did not get a follow-up test as planned, which led to a delay in diagnosis.


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