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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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Safety Spotlight: Investigations into equipment and technology used for continuous fetal heart rate monitoring

Safety spotlight

MNSI has completed Investigations into equipment and technology used for continuous fetal heart rate monitoring.
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Safety Spotlight: Deaths from Anaphylaxis

Safety spotlight

MNSI is aware of maternal deaths from anaphylaxis.
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Safety Spotlight: Therapeutic cooling practices

Safety spotlight

Our investigations into therapeutic cooling practices have identified areas of learning in relation to passive cooling.
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Safety Spotlight: Exchange blood transfusion

Safety spotlight

A baby received an exchange blood transfusion. This is a specialist and complex procedure with associated risks (and is now infrequently performed in most neonatal units).
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