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
- 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
- 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
- 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
- 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
- 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
- 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
- Assessment of risk of venous thromboembolism (VTE) when prescribing combined hormonal contraceptives
- Sucrose vial cap identified as potential choking hazard in babies