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HSIB report on design and safe use of portable oxygen systems

The reference event An 83-year-old man was admitted to hospital via the Emergency Department. He complained of feeling unwell for the previous few weeks, decreased appetite, vomiting after eating, loose stools and abdominal discomfort. A medical history of type 2...

The Human Factor – Learning from Gina’s story

Wrong implant never event report

The NHS strives to learn from its mistakes but is often criticised for failing to investigate incidents properly, and for failing to share lessons learned more widely. This report is a redacted report from a Never Event investigation. The Trust involved wishes to...

Top 10 Health Technology Hazards – ECRI Institute

Health technology hazards can come in many forms. They can be the result of IT-related problems such as improperly configured systems, incomplete data, or inappropriate malware protection. They can be caused by inappropriate human-device interaction, such as incorrect...