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Filter investigations by theme:
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Acute
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Missed diagnosis
Never events
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Undiagnosed condition
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Complete
Provision of mental health care to patients presenting at the emergency department
Start date:
20 Sep 2017
Theme:
Mental health
Complete
Piped supply of medical air and oxygen
Start date:
20 Nov 2018
Theme:
Never events
Ongoing
Identifying and reducing high-risk prescribing errors in hospital
Start date:
24 Oct 2018
Theme:
Medication
Ongoing
The diagnosis of ectopic pregnancy
Start date:
18 Oct 2018
Theme:
Delayed diagnosis
Complete
Management of chronic health conditions in prisons
Start date:
16 Oct 2018
Theme:
Transfers
Complete
Electronic prescribing and medicines administration systems and safe discharge
Start date:
12 Oct 2018
Theme:
Medication
Complete
Undetected button/coin cell battery ingestion in children
Start date:
1 Aug 2018
Theme:
Missed diagnosis
Complete
Failures in communication or follow-up of unexpected significant radiological findings
Start date:
10 Sep 2018
Theme:
Communication
Complete
Management of acute onset testicular pain
Start date:
27 Jun 2018
Theme:
Primary care
Complete
Recognising and responding to critically unwell patients
Start date:
12 Oct 2017
Theme:
Acute
Complete
Implantation of wrong prostheses during joint replacement surgery
Start date:
4 Dec 2017
Theme:
Surgery
Complete
Transition from child and adolescent mental health services to adult mental health services
Start date:
18 Oct 2017
Theme:
Mental health
Complete
Administering a wrong site nerve block
Start date:
12 Sep 2017
Theme:
Never events
Ongoing
Management of VTE risk in patients following thrombolysis for an acute stroke
Start date:
7 Feb 2019
Theme:
Acute
Ongoing
Potential under-recognised risk of harm from the use of propranolol
Start date:
18 Feb 2019
Theme:
Medication
Complete
Insertion of an incorrect intraocular lens
Start date:
29 Nov 2017
Theme:
Surgery
Complete
Design and safe use of portable oxygen systems
Start date:
29 Nov 2018
Theme:
Acute
Ongoing
Recognition of the acutely ill infant
Start date:
20 Mar 2019
Theme:
Missed diagnosis
Complete
Transfer of critically ill adults
Start date:
20 Jul 2017
Theme:
Transfers
Ongoing
Lack of timely monitoring for patients with glaucoma
Start date:
10 May 2019
Theme:
Outpatients
Complete
Wrong patient details on blood sample
Start date:
16 May 2019
Theme:
Acute
Ongoing
Detection of retained vaginal swabs and tampons following childbirth
Start date:
11 Jul 2019
Theme:
Acute
Complete
Inadvertent administration of an oral liquid medicine into a vein
Start date:
14 Nov 2017
Theme:
Medication
Ongoing
Delayed recognition of acute aortic dissection
Start date:
20 Jul 2017
Theme:
Delayed diagnosis
Ongoing
Undiagnosed cardiomyopathy in a young person with autism
Start date:
15 May 2019
Theme:
Undiagnosed condition
Ongoing
Procurement, usability and adoption of ‘smart’ infusion pumps
Start date:
21 Aug 2019
Theme:
Equipment and technology
Ongoing
Insulin prescribing and administration in hospitals
Start date:
24 Sep 2019
Theme:
Medication
Ongoing
Medication omission in mental health hospitals
Start date:
30 Sep 2019
Theme:
Mental health