Although funded by the Department of Health & Social Care and hosted by NHS Improvement, we operate independently. We're also independent from regulatory bodies like the Care Quality Commission (CQC). By offering a new perspective and developing meaningful and influential recommendations we aim to drive positive change at a wider level.
Inadvertent administration of an oral liquid medicine into a vein
Read our latest investigation report, including safety recommendations and observations.
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The investigation will focus on providing a Safety II approach to consider staff perspectives on blood sampling and labelling practice. Safety II considers how performance is adapted to respond to varying conditions and how these adaptations represent not only how things go wrong, but also how things usually go right.
Any person, group or organisation can share cases for potential investigation via the safety awareness form. Each submission is reviewed against our criteria, and an important part of assessment is whether we can learn something new that improves practice across the health system. We use a range of approaches focusing on establishing cause and identifying risk.