Get updates via RSS feed
Nutrition management of acutely unwell patients in acute medical units
published
Acute medical units (AMUs) are the first point of entry for patients referred to hospital as an emergency by their GP and those who require admission from emergency departments. This investigation seeks to support improvements in identification and management of nutritional needs in AMUs.
Read the summary
Published
-
Theme:
Acute, Hospital care, Continuity of care
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.
Read the summary
Published
-
Theme:
Medical devices, Checking, Surgical -
Awaiting safety recommendation responses
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.
Read the summary
Launched
-
Theme:
NHS staff, Patient safety themes
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.
Read the summary
Launched
-
Theme:
Emergency care, Communication and decision making, Continuity of care
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.
Read the summary
Launched
-
Theme:
NHS staff, Patient safety themes, Patient and family, Continuity of care
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.
Read the summary
Published
-
Theme:
Communication and decision making, Checking -
Safety recommendation responses received
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.
Read the summary
Published
-
Theme:
Acute, Respiratory -
Awaiting safety recommendation responses
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.
Read the summary
Published
-
Theme:
Primary care, Delayed diagnosis, Continuity of care -
Awaiting safety recommendation responses
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.
Read the summary
Published
-
Theme:
Medical devices -
Awaiting safety recommendation responses
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.
Read the summary
Published
-
Theme:
Hospital care, Learning disabilities -
Safety recommendation responses received