Resource library

This factsheet provides information about how to prevent ventilator-associated pneumonia (VAP) using an evidence-based practice VAP bundle.

This paper by Dr Arthur Morris, Dr Sally Roberts, Nikki Grae and Dr Chris Frampton highlights increased rates of infection following hip and knee arthroplasty when cefazolin is underdosed.

This report alerts providers to key findings of a recent review, and highlights changes put in place to stop such an event happening again.

This report aims to alert providers to the key findings of a recent review, with an update on new engineering standards being introduced worldwide to prevent Luer misconnections.

This report alerts providers to the key findings of a recent review and system changes made to prevent the incident happening again. In this case, changes were made to systems relating to loan instruments for specialised procedures.

This report alerts providers to key findings from three similar recent incident reviews at different hospitals.

This first trigger tool Open Book report focuses on cases from a hospital setting. Trigger tools are also used in primary care. The aim of this report is to encourage reflective learning using harm triggers identified in one organisation.

This report alerts providers to key findings and actions following review of an outbreak of a multi-drug resistant organism (MDRO) which affected five patients. The aim is to learn from the changes implemented after the event to prevent future simila

This report alerts providers to key findings and actions following review of a serious healthcare associated infection related to the insertion and management of a peripheral intravenous cannula (PIVC).

This report alerts providers to key findings and actions following review of delayed recognition of lack of red reflex in a newborn. The findings from this case extend across care settings, specialties and national guidance.