Patient safety investigations

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A nurse wearing scrubs prepares surgical instruments including swabs.

Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports

published
Retained swabs are classed as Never Events. Data shows there has been 11-23 retained swab incidents per year since 2015. The investigation was launched after we examined the case of a patient who had two swabs left in her chest following serious heart surgery.
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Published

  • Theme:

    Medical devices, Checking, Surgical

  • Awaiting safety recommendation responses

A tired hospital doctor rests his head on his hand as he sits at a desk.

Fatigue risk in healthcare and its impact on patient safety

Fatigue presents a potential significant risk to patient safety and staff wellbeing. In other safety-critical industries, fatigue is monitored and routinely considered as a potential contributory factor in safety incidents.
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Launched

  • Theme:

    NHS staff, Patient safety themes
Aerial view of a prison site in the English countryside.

Healthcare provision in prisons

We've analysed the patient safety issues frequently highlighted within prison healthcare to identify themes. Our team is visiting prisons across England to investigate emergency care, continuity of care and data sharing and IT.
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Launched

  • Theme:

    Emergency care, Communication and decision making, Continuity of care
A smiling health visitor wearing green scrubs helps an older woman to walk in her home.

Safety management systems

These investigations consider how safety management is coordinated and integrated across the healthcare system. They look at accountability beyond organisational boundaries and involving NHS staff and patients.
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Launched

  • Theme:

    NHS staff, Patient safety themes, Patient and family, Continuity of care
A male patient's hand rests on a nurse call button in a hospital bed

Positive patient identification

published
We've undertaken several investigations where misidentification of patients has been an important part of a patient safety event. This national learning report collates findings and identifies how these misidentifications have been able to happen.
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Published

  • Theme:

    Communication and decision making, Checking

  • Awaiting safety recommendation responses

An anaesthetist performs a nasotracheal intubation of a child.

Advanced airway management in patients with a known complex disease

published
This investigation explores intubation of patients with difficult airways. There are no standards for how an anticipated difficult airway is managed. Failure to provide an adequate airway can result in brain injury or death.
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Published

  • Theme:

    Acute, Respiratory

  • Awaiting safety recommendation responses

An older male patient talks to a GP, sat either side of a desk in a consulting room.

Continuity of care: delayed diagnosis in GP practices

published
While some GP practices in England operate a formalised system of continuity of care, many do not. This investigation explores the safety risk associated with the lack of a system of continuity of care within GP practices.
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Published

  • Theme:

    Primary care, Delayed diagnosis, Continuity of care

  • Awaiting safety recommendation responses

A nurse speaks to a cancer patient.

Risks to medication delivery using ambulatory infusion pumps: design and usability in inpatient settings

published
Ambulatory infusion pumps are small, battery powered medical devices. This investigation aims to improve patient safety by supporting healthcare staff in the safe use of ambulatory (portable) infusion pumps.
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Published

  • Theme:

    Medical devices

  • Awaiting safety recommendation responses

A nurse helps an older male patient to stand up from his hospital bed.

Caring for adults with a learning disability in acute hospitals

published
This investigation explores the care that people with learning disabilities receive in NHS hospitals. It specifically looks at the provision of healthcare to adults with learning disabilities within acute hospital settings.
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Published

  • Theme:

    Hospital care, Learning disabilities

  • Safety recommendation responses received

A space shuttle launches into a blue sky.

Safety management systems: an introduction for healthcare

published
Safety management systems are an organised approach to managing safety which are widely used in different industries. This national learning report looks at what could be achieved by further adopting this approach in healthcare.
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Published

  • Theme:

    NHS staff, Patient safety themes, Patient and family

  • Safety recommendation responses received

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