Resource library

This edition of Open Book was written in collaboration with the Health Quality & Safety Commission’s Reducing Harm from Falls programme, and sets out a series of practice changes made by providers to prevent patients from being harmed by falling.

This Open Book illustrates the importance of providers standardising the way they apply well-recognised safety steps.

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.