NHS England: How we acted on patient safety issues you recorded

Summary

Where a new or under-recognised risk identified through the NHS England's review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, NHS England look to work with partner organisations, who may be better placed to take action to address the issue.

To highlight this work and show the importance of recording patient safety events, they publish regular case studies.

These case studies show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.

Content

Latest case studies:

Urgent/emergency care

• Delayed oxygenation of neonate during resuscitation when oxygen not ‘flicked’ on
• Equipment falling onto critically ill patients during intrahospital transfers
• Misapplication of spinal collars resulting in harm from unsecured spinal injury
• Ensuring compatibility between defibrillators and associated defibrillator pads
• Ensuring pregnant women with COVID-19 symptoms access appropriate care

General medicine

• Harm from catheterisation in patients with implanted artificial urinary sphincters
• Confusion between different strength preparations of alfentanil
• Ensuring compatibility between defibrillators and associated defibrillator pads
• Distinguishing between haemofilters and plasma filters to reduce mis-selection
• Variation in use of cardiac telemetry
• Ceftazidime as a 24-hour infusion
• Tacrolimus – risk of overdose when converting from oral to intravenous route
• Haloperidol prescribing for confused/agitated/delirious patients
• Ensuring oxygen delivery when using two step humification systems

Intensive care

• Ventilator left in standby mode
• Equipment falling onto critically ill patients during intrahospital transfers
• Ensuring compatibility between defibrillators and associated defibrillator pads
• Distinguishing between haemofilters and plasma filters to reduce mis-selection
• Sudden patient deterioration due to secretions blocking heat and moisture exchanger filters
• Anaesthetic machines used as ventilators: issues with circuit set up
• Importance of ‘tug test’ for checking oxygen hose when transferring a patient to a portable ventilator
• Ensuring oxygen delivery when using two step humification systems

Obstetrics and gynaecology/midwifery

• Harm from prescribing and administering Syntometrine when contraindicated to woman with significantly raised BP
• Delayed oxygenation of neonate during resuscitation when oxygen not ‘flicked’ on
• Unnecessary caesarean section for breech presentation if not scanned on the day
• HIV prophylaxis in women and new-borns
• Ensuring compatibility between defibrillators and associated defibrillator pads
• Ensuring the safe use of plastic cord clamps at caesarean section
• Warning on the use of ethyl chloride during fetal blood sampling
• Ensuring pregnant women with COVID-19 symptoms access appropriate care
• Risk of babies becoming unwell following move to virtual home midwifery visits

Paediatrics and child health

• Ensuring compatibility between defibrillators and associated defibrillator pads
• Risk of babies becoming unwell following move to virtual home midwifery visits
• Unintentional perforation of oesophagus in neonates from invasive procedures
• Chemical burn to a neonate from use of chlorhexidine

Other

• Ensuring compatibility between defibrillators and associated defibrillator pads
• Infrared temperature screening to detect COVID-19