Where a new or under-recognised risk identified through our review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, we 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, we 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.
Latest case studies
- Risk of airway obstruction from green anaesthetic swabs
- Retained surgical instrumentation and complex procedures involving multiple teams and equipment
- Risks of ingestion of alcohol-based hand sanitiser
- ePrescribing systems and insulin combinations
- Surgical skin preparation solution entering the eye during surgery
- Retention of Mydriasert insert post ophthalmic surgery
- Bone cement implantation syndrome
- Hip cement – different expiry dates for separate components in the same pack
- Overdose of oral vitamin D related to frequency and duration of treatment
- Monitoring patients taking nitrofurantoin for potential lung disease
- Use of trimethoprim in women of child-bearing age
- Risk of dose error when using intraosseous lidocaine in children
- Risk of harm from spinal administration of anaesthetic agent containing preservative
- COVID-19 swab snapped in tracheostomy
You can also find all our ‘How we acted on patient safety issues you recorded’ case studies, categorised by clinical specialty, via the link below.
Our National Patient Safety Alerts webpage also provides links to all alerts issued by the NHS England national patient safety team. You can also find more case studies and information in the Patient safety review and response reports we previously published between 2016 – 2019.
As well as supporting us to identify new or under recognised safety issues, the information from records of patient safety events also supports ongoing improvement work to tackle the more common and well-known patient safety challenges, such as reducing diagnostic error, preventing self-harm, avoiding falls or managing long-term anticoagulation. These issues have complex causes and no simple solutions, and are the focus of long-term improvement work, including the NHS England National Patient Safety Improvement Programmes.
You can find out more about our processes for identifying new and under recognised patient safety issues on our Using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.