
The use of an appropriate flush fluid with arterial lines
published
This investigation aims to understand the risks for patients associated with blood sampling from arterial line systems used in adult critical care.
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Published
-
Theme:
Medical devices, Medication, Checking -
Awaiting safety recommendation responses

Positive patient identification
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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Launched
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Theme:
Communication and decision making, Checking

Detection of jaundice in newborn babies
We have launched an investigation into the detection of jaundice in newborn babies.
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Launched
-
Theme:
Neonatal, Missed diagnosis

Local integrated investigation pilot 2: Incorrect patient details on handover
published
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.
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Published
-
Safety recommendation responses received

Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to emergency care
published
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.
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Published
-
Theme:
Emergency care

Local integrated investigation pilot 1: Incorrect patient identification
published
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.
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Published
-
Theme:
Analysis -
Safety recommendation responses received

Invasive procedures in patients with sickle cell disease
This investigation looks at the risks for patients with sickle cell disease when they undergo invasive procedures in hospital. It explores how hospital specialities can ensure that patients with sickle cell disease are prepared for procedures which could put them at risk of a sickle cell crisis.
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Launched
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Theme:
Long-term conditions, Communication and decision making

Recognition of the acutely ill infant
published
We were notified of a three-month-old infant who was admitted to hospital and discharged four hours later. The infant was re-admitted less than four hours later and sadly died of Meningococcus (serogroup B).
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Published
-
Theme:
Emergency care, Communication and decision making -
Safety recommendation responses received

Emergency neonatal blood transfusion at birth following acute blood loss during labour and/or delivery
published
This investigation looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. Delays in neonatal blood transfusion emerged as a safety risk from investigations carried out under our maternity investigation programme.
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Published
-
Theme:
Neonatal, Maternity -
Safety recommendation responses received

Undiagnosed cardiomyopathy in a young person with autism
published
People with additional needs receiving care in hospital may require adjustments to promote their safety and improve their experience of care. This investigation seeks to understand the safety risks associated with patients with additional needs, as highlighted in the reference event.
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Published
-
Theme:
Long-term conditions, Communication and decision making -
Safety recommendation responses received