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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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Maternal Care Bundle safety spotlights

Safety spotlight

We welcome the publication of the Maternal Care Bundle by NHS England and are delighted to have been a key contributor in its development. A series of safety spotlights follow.
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Safety spotlight: Late diagnosis of breech presentation

Safety spotlight

MNSI has completed a number of investigations where there has been a late diagnosis, in established labour, of a baby being in breech presentation during an induction of labour.
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