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Summary

When something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else."

These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what the Care Quality Commission (CQC) and the provider have done about it, and the steps you can take to avoid it happening in your service.

Content

Issue 13: Protecting people using wheelchairs

Issue 12: Capacity and consent

Issue 11: Promoting sexual safety

Issue 10: Unsafe management of sepsis

Issue 9: Medicines management - assessment

Issue 8: Hypothermia

Issue 7: Falls from windows

Issue 6: Caring for people at risk of choking

Issue 5: Safe management of medicines - treatment

Issue 4: Burns from hot water or surfaces

Issue 3: Fire risk from use of emollient creams

Issue 2: Unsafe use of bed rails

Issue 1: Falls from improper use of equipment

CQC: Learning from safety incidents (22 April 2022) https://www.cqc.org.uk/guidance-providers/learning-safety-incidents

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Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

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