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Safety spotlight: Nitrous oxide

Safety spotlight

This safety spotlight shares what we found regarding nitrous oxide decommissioning and offers prompts to help providers keep staff informed and equipment checks consistent.
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Briefing paper: Newborn cooling practices

Briefing paper

MNSI has reviewed 20 investigations into the cooling of term babies across England. The findings show that national guidance on continuous temperature monitoring during cooling was not followed in half of cases.
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Safety spotlight: Mothers with a learning disability

Maternity care should be responsive to every woman’s needs.
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Safety spotlight: Reviewing and actioning laboratory test results

MNSI has undertaken investigations where laboratory test results have not been reviewed and actioned.
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Safety Spotlight: Changes to the MNSI investigation report template

Safety spotlight

On 1st April 2024, six months after the transition to being hosted by the CQC, MNSI changed their investigation reports and process.
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Safety Spotlight: Maternal Deaths in the first trimester from Venous Thromboembolism (VTE)

Safety spotlight

MNSI has undertaken investigations of maternal deaths in the first trimester from venous thromboembolism (VTE)
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Safety Spotlight: Incomplete observations generating incorrect EWS

Safety spotlight

MNSI has investigated a number of patient safety events where an incomplete set of observations generated an early warning score (EWS) via an electronic patient record (EPR) system.
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Safety Spotlight: Prescribing and dispensing of low molecular weight heparin

Safety spotlight

Things MNSI recommend considering when prescribing low molecular weight heparin to avoid incorrect doses being dispensed.
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Safety Spotlight: Patient Ethnicity Data Collection

Safety spotlight

MNSI has found that inaccurate or missing recordings of a woman’s ethnicity have impacted her subsequent pathway of care.
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Safety Spotlight: Delayed escalation in abnormal CTGs

Safety spotlight

MNSI has completed a number of investigations in which time limits, as described in national guidance, have delayed categorisation of CTG recordings, resulting in delays in escalation.
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