Search Results for: 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).

MNSI has found that inaccurate or missing recordings of a woman’s ethnicity have impacted her subsequent pathway of care.

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.

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.

On 1st April 2024, six months after the transition to being hosted by the CQC, MNSI made changes to their investigation reports and process.

Things MNSI recommend considering when prescribing low molecular weight heparin to avoid incorrect doses being dispensed.

MNSI has undertaken investigations of maternal deaths in the first trimester from venous thromboembolism (VTE). Two recurrent features in these investigations.