Displaying 481 - 490 of 640 results
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Open Book: Surgery abandoned due to unavailable instruments (December 2015)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.
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Open Book: Retained vaginal swabs following childbirth (December 2015)This report alerts providers to findings from review of cases reported to the Health Quality & Safety Commission involving retained vaginal swabs after childbirth. It includes a summary of evidence and prevention strategies for providers to consider.
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Open Book: Ensuring referrals happen (February 2016)This report alerts providers to key findings from three similar recent incident reviews at different hospitals.
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Open Book: Delay due to the use of an unfamiliar acronym (February 2016)This report alerts providers to the potential danger of using unfamiliar acronyms in communications between services.
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Open Book: Reviewing trigger tool notes to uncover harm (April 2016)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.
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Open Book: Transmission of 'super-bug' in hospital (May 2016)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
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Open Book: Bloodstream infection related to peripheral intravenous cannula (May 2016)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).
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Open Book: Red reflex assessment in newborns (June 2016)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.
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Open Book: Incorrect assembly of surgical equipment (June 2016)This report alerts providers to key findings and actions following review of two incidents in different organisations where surgical equipment was assembled incorrectly resulting in patient harm in the operating theatre.
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National Adverse Events policy 2017National Adverse Events policy 2017