Patient safety review and response case studies by clinical specialty
This page shows case studies, listed by clinical specialty, of where the National Patient Safety Team worked with partners to address issues identified through its review of recorded patient safety events.
- Urgent/emergency care
- General medicine
- Intensive care
- Obstetrics and gynaecology/midwifery
- Paediatrics and child health
- Surgery
- Primary care
- Other
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.
Urgent/emergency care
- Inpatient falls and brain injury
- Patient entrapment in beds, bed rails and related devices
- Correct identification of insulin patch pumps on patients
- COVID-19 swab snapped in tracheostomy
- Risk of dose error when using intraosseous lidocaine in children
- ePrescribing systems and insulin combinations
- Risks of ingestion of alcohol-based hand sanitiser
- Risk of airway obstruction from green anaesthetic swabs
- Dual purpose naso-gastric tubes with ENFit® connectors and the risk of aspiration
- Diagnosis and management of supraglottitis
- Sucrose vial cap identified as potential choking hazard in babies
- The risk of aspiration from orally administered contrast media with spigotted nasogastric tubes
- Metacarpal wrong site surgery – inconsistent terminology used to describe anatomy
- Osmotic Demyelination Syndrome from rapid correction of severe hypo/hypernatraemia
- Ensuring timely updates to clinical risk assessment and management triage tools in emergency departments
- Ingested gel toilet discs
- 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
- Risk of blockage of enteral feeding tubes if hydrocortisone granules are administered via this route
- Inpatient falls and brain injury
- Patient entrapment in beds, bed rails and related devices
- COVID-19 swab snapped in tracheostomy
- Overdose of oral vitamin D related to frequency and duration of treatment
- ePrescribing systems and insulin combinations
- Administration of chemotherapy and reactivation of Hepatitis B
- Delay in treatment with prothrombin complex concentrate (PCC)
- The risk of aspiration from orally administered contrast media with spigotted nasogastric tubes
- Osmotic Demyelination Syndrome from rapid correction of severe hypo/hypernatraemia
- 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
- Potential for aspiration of absorbent haemostatic gauze
- Inpatient falls and brain injury
- Patient entrapment in beds, bed rails and related devices
- Anaesthetic vapour delivered inadvertently
- COVID-19 swab snapped in tracheostomy
- ePrescribing systems and insulin combinations
- Risks of ingestion of alcohol-based hand sanitiser
- Risk of airway obstruction from green anaesthetic swabs
- Dual purpose naso-gastric tubes with ENFit® connectors and the risk of aspiration
- The risk of aspiration from orally administered contrast media with spigotted nasogastric tubes
- Pregnancy tests not performed before anaesthesia
- Osmotic Demyelination Syndrome from rapid correction of severe hypo/hypernatraemia
- 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
- Inpatient falls and brain injury
- Patient entrapment in beds, bed rails and related devices
- COVID-19 swab snapped in tracheostomy
- Use of trimethoprim in women of child-bearing age
- ePrescribing systems and insulin combinations
- Risks of ingestion of alcohol-based hand sanitiser
- Assessment of risk of venous thromboembolism (VTE) when prescribing combined hormonal contraceptives
- Osmotic Demyelination Syndrome from rapid correction of severe hypo/hypernatraemia
- 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
- Use of liquid preparations of phenobarbital in children
- Risk of blockage of enteral feeding tubes if hydrocortisone granules are administered via this route
- Use of effervescent tablets to administer doses of calcium and phosphate supplements to children
- Inpatient falls and brain injury
- Patient entrapment in beds, bed rails and related devices
- COVID-19 swab snapped in tracheostomy
- Risk of dose error when using intraosseous lidocaine in children
- ePrescribing systems and insulin combinations
- Risks of ingestion of alcohol-based hand sanitiser
- Sucrose vial cap identified as potential choking hazard in babies
- Testing ammonia levels in children
- 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
Surgery
- Risk of blockage of enteral feeding tubes if hydrocortisone granules are administered via this route
- Potential for aspiration of absorbent haemostatic gauze
- Inadvertent use of 100% alcohol on ocular surface
- Inpatient falls and brain injury
- Patient entrapment in beds, bed rails and related devices
- Anaesthetic vapour delivered inadvertently
- COVID-19 swab snapped in tracheostomy
- Risk of harm from spinal administration of anaesthetic agent containing preservative
- Hip cement – different expiry dates for separate components in the same pack
- Bone cement implantation syndrome
- Surgical skin preparation solution entering the eye during surgery
- ePrescribing systems and insulin combinations
- Risks of ingestion of alcohol-based hand sanitiser
- Retained surgical instrumentation and complex procedures involving multiple teams and equipment
- Risk of airway obstruction from green anaesthetic swabs
- Dual purpose naso-gastric tubes with ENFit® connectors and the risk of aspiration
- Delay in treatment with prothrombin complex concentrate (PCC)
- The risk of aspiration from orally administered contrast media with spigotted nasogastric tubes
- Unintentional retention of bone cement following hip surgery
- Pregnancy tests not performed before anaesthesia
- Metacarpal wrong site surgery – inconsistent terminology used to describe anatomy
Primary care
- Use of liquid preparations of phenobarbital in children
- Use of effervescent tablets to administer doses of calcium and phosphate supplements to children
- Inpatient falls and brain injury
- Patient entrapment in beds, bed rails and related devices
- COVID-19 swab snapped in tracheostomy
- Use of trimethoprim in women of child-bearing age
- Monitoring patients taking nitrofurantoin for potential lung disease
- Overdose of oral vitamin D related to frequency and duration of treatment
- ePrescribing systems and insulin combinations
- Risks of ingestion of alcohol-based hand sanitiser
- Assessment of risk of venous thromboembolism (VTE) when prescribing combined hormonal contraceptives
- Sucrose vial cap identified as potential choking hazard in babies