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:
- Ingested gel toilet discs
- Testing ammonia levels in children
- Ensuring timely updates to clinical risk assessment and management triage tools in emergency departments.
- Osmotic Demyelination Syndrome from rapid correction of severe hypo/hypernatraemia
- Metacarpal wrong site surgery – inconsistent terminology used to describe anatomy
- Assessment of risk of venous thromboembolism (VTE) when prescribing combined hormonal contraceptives
- Pregnancy tests not performed before anaesthesia
- Unintentional retention of bone cement following hip surgery
- The risk of aspiration from orally administered contrast media with spigotted nasogastric tubes
- Delay in treatment with prothrombin complex concentrate (PCC)
- Sucrose vial cap identified as potential choking hazard in babies
- Administration of chemotherapy and reactivation of Hepatitis B
- Unintended bolus of medication if infused at speed from residual space in giving set
- Diagnosis and management of supraglottitis
- Dual purpose naso-gastric tubes with ENFit® connectors and the risk of aspiration
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.