Case studies
| Action to reduce harm to patients in emergency care settings |
| In March 2022, we launched an investigation looking at the harm that is caused to patients when there is delays in transferring them to the right place of care.8 During investigations we may publish what is known as an interim bulletin but in this case, we have published three interim bulletins which we have never done before (two bulletins also contain safety recommendations to DHSC and NHSE). This was to ensure that we were communicating what we had found so far from a patient safety perspective, given the urgent nature of the challenges currently being seen in emergency care. The investigation is ongoing but the calls to action in the bulletins have received support from those working in on the frontlines of urgent and emergency care and leaders in national healthcare organisations (such as the Association of Ambulance Chief Executives). The high-profile coverage of the interim reports means our commentary on what are seeing in our investigation has reached a wider public level and have resulted in referrals, with people sharing their own experiences with HSIB. The three areas the bulletins covered are patient flow through hospitals,9 patient safety accountability 10 and staff wellbeing.11 |
| MHRA issue drug safety update in response to HSIB report |
| The Medicines and Healthcare products Regulatory Agency (MHRA) produced a drug safety update12 in January 2023 in response to our report on weight-based medication errors in children.13 The investigation was undertaken following a case in which a child received a 10-times overdose of an anticoagulant medicine due to errors in the prescription, dispensing and administration processes. Our report noted that although electronic prescribing and medicines administration systems (ePMAS) are considered an effective way to reduce medication errors, they may cause new technology-related errors. The MHRA has been undertaking work with manufacturers of ePMAS devices to improve reporting of potential errors with ePMAS to MHRA, to reduce these risks. |