Resource library

This Open Book describes changes made as a result of X-ray results not being responded to appropriately. The unifying theme for both incidents described is that there was no fail-safe step in the sign-off of results.

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 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 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.

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

This report alerts providers to the potential danger of using unfamiliar acronyms in communications between services.

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