Core eight

Use the headings below to click through and comment on each individual event.

Wrong site surgery

A surgical intervention performed on the wrong site (for example wrong knee, wrong eye, wrong patient, wrong limb, or wrong organ).

Retained instrument post-operation

One or more instruments or swabs, or a throat pack, are unintentionally retained following an operative procedure.

Chemotherapy administration

Wrong route administration of chemotherapy.

Misplaced naso or orgastric tubes

Misplaced naso or orogastric tube not detected prior to use.

Inpatient suicide

Inpatient suicide using non-collapsible rails.

Escape from secure mental health services

Escape from within the secure perimeter of medium or high secure mental health services by patients who are transferred prisoners.

Maternal death

In-hospital maternal death from post-partum haemorrhage after elective caesarean section.

Potassium chloride

Intravenous administration of mis-selected concentrated potassium chloride.

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