The safety watchdog has been busy over the past few months. In May, June and July respectively the Healthcare Safety Investigation Branch published the following final reports:
- Recognising and responding to critically unwell patients
- Undetected button and coin cell battery ingestion in children
- Failures in communication or follow up of unexpected significant radiological findings
Those working in ambulance trusts or for out-of-hours and acute providers may like to take a look at our blogs on each of them to pick up some risk management tips. However there are pointers for those working in other environments too.
If these are not enough holiday reading for you we note that an interim bulletin has just been published on Identifying and reducing high risk prescribing errors in hospital. This investigation was triggered by HSIB identifying incidents relating to incorrect prescribing of warfarin via their ongoing monitoring of NHS incident reporting systems.
Jill Mason, Partner and Head of Health and Care
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