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Open Book: Lessons learnt from reviewing patient falls (March 2017)

29 Mar 2017, Adverse Events

Falls are one of the most common causes of injury to patients in hospital. This Open Book was written in collaboration with the Health Quality & Safety Commission’s Reducing Harm from Falls programme. It summarises four falls events, review findings and r

Open Book: Transmission of 'super-bug' in hospital (May 2016)

20 May 2016, Adverse Events

This report alerts providers to key findings and actions following review of an outbreak of a multi-drug resistant organism (MDRO) which affected five patients. The aim is to learn from the changes implemented after the event to prevent future similar eve

The Global Trigger Tool: A review of the evidence

1 Feb 2016, Adverse Events

This report reviews the literature associated with the development and use of trigger tools to determine rates of harm in health care settings, with particular attention on the Institute of Healthcare Improvement's Global Trigger Tool.