The HSIB were made aware of a nine-year-old child who inadvertently had an oral liquid medication injected into a vein. The initial investigation highlighted steps missing in the preparation, checking and administration of the prescribed drug. The full investigation will look at the complexity of the medications process, applying a human factors view to aid learning.
Interim bulletins are released to share further details of each investigation, including how it’s met HSIB criteria, the history of the event it relates to, the national context and any identified safety issues.
The HSIB launched its first full investigation in July 2017, and is now carrying out nine full investigations.