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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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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: HbA1c testing in women with sickle cell trait

Safety spotlight

Laboratory tests for glycosylated haemoglobin (HbA1c) can underestimate past glycaemia in people with haemoglobin variants, such as those with sickle cell trait. This is because there is an increased red cell turnover in those with haemoglobin variants. This means that HbA1c tests, which estimate t…
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Neonatal collapse alongside skin-to-skin contact

National learning report

HSIB legacy publication

National learning report
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Annual publication of maternity safety investigation recommendations 2023 to 2024

Safety recommendations

MNSI publishes the safety recommendations from MNSI investigations completed in 2023/24.
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Second COMPASS programme launched

Programme

We are announcing today a second pilot programme of our innovative assessment tool designed to examine the impact of organisational culture on safe care. The initial pilot of the MNSI tool, called COMPASS – Culture of Organisations and its iMpact on PAtientS’ Safety ­­– ran in spring 2025.
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