This report aims to alert providers to the key findings of a recent adverse event review. The emphasis is on the changes implemented by the provider involved to stop the event happening again. We advise providers to consider this report, and whether the changes made are relevant to their own systems.
This report is for:
- staff on wards and units providing direct care to patients
- staff on units where patients receive therapy or investigations
- training and education programme planners
- staff who collect patients and transport them between departments.
