Displaying 461 - 470 of 614 results
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Open Book: Safe discharge processes – norovirus (August 2015)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.
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Open Book: Epidural medicines through intravenous lines (September 2015)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.
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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.