Although funded by the Department of Health & Social Care and hosted by NHS England and 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
We made safety recommendations to NHS Improvement and the Royal of College of Physicians as a result of this investigation.
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We launched this investigation after we were notified of three incidents where an accidental fentanyl overdose occurred. The Trust had administered the powerful pain medication using a smart pump.
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.