Surgery Patient safety resources from the NRLSGuidance and alerts to help improve patient safety in surgeryHarm from flushing of nasogastric tubes before confirmation of placement22/03/2012http://www.nrls.npsa.nhs.uk/resources/?EntryId45=133441Tue, 20 Mar 2012 18:19:57 GMT20120320061957Tue, 20 Mar 2012 18:19:57 GMT20120320061957Fri, 20 Apr 2012 15:40:14 GMT20120420034014Risk of skin-prep related fire in operating theatres Signal28/02/2012http://www.nrls.npsa.nhs.uk/resources/?EntryId45=132981Fri, 02 Mar 2012 13:09:49 GMT20120302010949Fri, 02 Mar 2012 13:09:49 GMT20120302010949Fri, 02 Mar 2012 13:47:14 GMT20120302014714Risk of harm following gastric bypass Signal28/02/2012http://www.nrls.npsa.nhs.uk/resources/?EntryId45=132979Fri, 02 Mar 2012 12:45:45 GMT20120302124545Fri, 02 Mar 2012 12:45:45 GMT20120302124545Fri, 02 Mar 2012 13:48:57 GMT20120302014857Recognising and instigating prompt treatment for necrotising fasciitis Signal28/02/2012http://www.nrls.npsa.nhs.uk/resources/?EntryId45=132976Thu, 16 Feb 2012 11:01:53 GMT20120216110153Thu, 16 Feb 2012 11:01:53 GMT20120216110153Fri, 02 Mar 2012 12:16:15 GMT20120302121615Prevention of Harm with Buccal Midazolam Signal28/02/2012http://www.nrls.npsa.nhs.uk/resources/?EntryId45=132975Thu, 16 Feb 2012 10:53:07 GMT20120216105307Thu, 16 Feb 2012 10:53:07 GMT20120216105307Fri, 02 Mar 2012 12:20:54 GMT20120302122054Patient safety issues related to gastrostomy Signal28/02/2012http://www.nrls.npsa.nhs.uk/resources/?EntryId45=132974Thu, 16 Feb 2012 10:42:25 GMT20120216104225Thu, 16 Feb 2012 10:42:25 GMT20120216104225Wed, 18 Apr 2012 09:38:20 GMT20120418093820Diagnosis of death after cessation of cardiopulmonary resuscitation Signal28/02/2012http://www.nrls.npsa.nhs.uk/resources/?EntryId45=132973Thu, 16 Feb 2012 10:32:25 GMT20120216103225Thu, 16 Feb 2012 10:32:25 GMT20120216103225Fri, 09 Mar 2012 15:39:45 GMT20120309033945Risk of harm from CPM syndrome following rapid correction of sodium Signal28/02/2012http://www.nrls.npsa.nhs.uk/resources/?EntryId45=132971Thu, 16 Feb 2012 10:02:23 GMT20120216100223Thu, 16 Feb 2012 10:02:23 GMT20120216100223Fri, 30 Mar 2012 14:09:43 GMT20120330020943Minimising Risks of Mismatching Spinal, Epidural and Regional Devices with Incompatible Connectors28/11/2011http://www.nrls.npsa.nhs.uk/resources/?EntryId45=132897Mon, 28 Nov 2011 13:08:09 GMT20111128010809Mon, 28 Nov 2011 13:08:09 GMT20111128010809Mon, 28 Nov 2011 13:15:57 GMT20111128011557Outbreak of prosthetic valve endocarditis Signal25/03/2011http://www.nrls.npsa.nhs.uk/resources/?EntryId45=130186Thu, 24 Mar 2011 13:00:52 GMT20110324010052Thu, 24 Mar 2011 13:00:52 GMT20110324010052Fri, 25 Mar 2011 11:17:22 GMT20110325111722Early detection and treatment of acute limb ischaemia Signal25/03/2011http://www.nrls.npsa.nhs.uk/resources/?EntryId45=130172Thu, 24 Mar 2011 10:53:28 GMT20110324105328Thu, 24 Mar 2011 10:53:28 GMT20110324105328Fri, 25 Mar 2011 11:16:17 GMT20110325111617Airway suction equipment Signal14/02/2011http://www.nrls.npsa.nhs.uk/resources/?EntryId45=94845Mon, 07 Feb 2011 17:14:24 GMT20110207051424Mon, 07 Feb 2011 17:14:24 GMT20110207051424Mon, 14 Feb 2011 13:33:40 GMT20110214013340Safer spinal (intrathecal), epidural and regional devices31/01/2011http://www.nrls.npsa.nhs.uk/resources/?EntryId45=94529Mon, 31 Jan 2011 14:43:17 GMT20110131024317Mon, 31 Jan 2011 14:43:17 GMT20110131024317Tue, 13 Mar 2012 13:41:53 GMT20120313014153How to guide to the five steps to safer surgery20/12/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=92901Mon, 13 Dec 2010 11:23:08 GMT20101213112308Mon, 13 Dec 2010 11:23:08 GMT20101213112308Mon, 20 Dec 2010 10:45:43 GMT20101220104543Team Self Review08/12/2008http://www.nrls.npsa.nhs.uk/resources/?EntryId45=92755Wed, 08 Dec 2010 16:20:59 GMT20101208042059Wed, 08 Dec 2010 16:20:59 GMT20101208042059Wed, 08 Dec 2010 17:04:31 GMT20101208050431WHO surgical safety checklist: for maternity cases only11/11/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=83972Fri, 05 Nov 2010 10:01:37 GMT20101105100137Fri, 05 Nov 2010 10:01:37 GMT20101105100137Mon, 20 Dec 2010 13:05:26 GMT20101220010526Haemorrhage following removal of femoral catheters Signal29/10/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=83805Wed, 27 Oct 2010 14:50:36 GMT20101027025036Wed, 27 Oct 2010 14:50:36 GMT20101027025036Thu, 28 Oct 2010 11:23:34 GMT20101028112334Accurate patient weight Signal29/10/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=83756Mon, 25 Oct 2010 14:08:07 GMT20101025020807Mon, 25 Oct 2010 14:08:07 GMT20101025020807Mon, 18 Apr 2011 16:29:21 GMT20110418042921Wrong site nerve block Signal29/10/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=83755Mon, 25 Oct 2010 13:59:45 GMT20101025015945Mon, 25 Oct 2010 13:59:45 GMT20101025015945Thu, 28 Oct 2010 11:26:02 GMT20101028112602The transfusion of blood and blood components in an emergency21/10/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=83659Tue, 19 Oct 2010 15:54:00 GMT20101019035400Tue, 19 Oct 2010 15:54:00 GMT20101019035400Thu, 21 Oct 2010 12:55:54 GMT20101021125554Never Events Annual Report 2009/1008/10/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=83319Wed, 06 Oct 2010 11:42:55 GMT20101006114255Wed, 06 Oct 2010 11:42:55 GMT20101006114255Fri, 08 Oct 2010 16:43:08 GMT20101008044308Design for patient safety: user testing in the development of medical devices01/03/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=74946Fri, 09 Jul 2010 11:47:36 GMT20100709114736Fri, 09 Jul 2010 11:47:36 GMT20100709114736Tue, 13 Jul 2010 15:26:33 GMT20100713032633High Hazards- summary and full report01/03/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=74930Thu, 08 Jul 2010 12:03:16 GMT20100708120316Thu, 08 Jul 2010 12:03:16 GMT20100708120316Fri, 09 Jul 2010 13:47:12 GMT20100709014712Pembury: summary report01/03/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=74918Wed, 07 Jul 2010 16:33:58 GMT20100707043358Wed, 07 Jul 2010 16:33:58 GMT20100707043358Mon, 12 Jul 2010 09:22:03 GMT20100712092203WHO Surgical Safety Checklist: for cataract surgery only27/05/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=74132Thu, 27 May 2010 09:39:09 GMT20100527093909Thu, 27 May 2010 09:39:09 GMT20100527093909Mon, 19 Jul 2010 17:33:11 GMT20100719053311Checking pregnancy before surgery28/04/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=73838Fri, 23 Apr 2010 11:01:58 GMT20100423110158Fri, 23 Apr 2010 11:01:58 GMT20100423110158Wed, 28 Apr 2010 13:16:36 GMT20100428011636Never Events - Framework: Update for 2010-1124/03/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=68518Wed, 24 Mar 2010 10:42:27 GMT20100324104227Wed, 24 Mar 2010 10:42:27 GMT20100324104227Mon, 17 May 2010 09:45:37 GMT20100517094537Injectable medicines in theatres Signal26/02/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=66753Thu, 25 Feb 2010 09:51:32 GMT20100225095132Thu, 25 Feb 2010 09:51:32 GMT20100225095132Tue, 09 Mar 2010 11:36:25 GMT20100309113625Transferring neurosurgery patient images Signal26/02/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=66738Wed, 24 Feb 2010 16:43:01 GMT20100224044301Wed, 24 Feb 2010 16:43:01 GMT20100224044301Tue, 09 Mar 2010 11:23:21 GMT20100309112321Placenta Praevia after Caesarean Section Care Bundle10/02/2010http://www.nrls.npsa.nhs.uk/resources/?EntryId45=66359Wed, 10 Feb 2010 15:32:29 GMT20100210033229Wed, 10 Feb 2010 15:32:29 GMT20100210033229Thu, 22 Jul 2010 17:29:34 GMT20100722052934Right patient, right blood: core competencies09/11/2006http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65838Thu, 07 Jan 2010 10:28:30 GMT20100107102830Thu, 07 Jan 2010 10:28:30 GMT20100107102830Fri, 05 Nov 2010 16:05:57 GMT20101105040557Reducing the risks of tourniquets left on after finger and toe surgery09/12/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65568Wed, 09 Dec 2009 09:22:06 GMT20091209092206Wed, 09 Dec 2009 09:22:06 GMT20091209092206Wed, 09 Dec 2009 16:32:24 GMT20091209043224Wrong side biopsy Signal27/11/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65336Fri, 27 Nov 2009 10:16:42 GMT20091127101642Fri, 27 Nov 2009 10:16:42 GMT20091127101642Tue, 09 Mar 2010 13:04:49 GMT20100309010449Distance to travel for key on-call staff Signal27/11/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65334Fri, 27 Nov 2009 10:03:03 GMT20091127100303Fri, 27 Nov 2009 10:03:03 GMT20091127100303Tue, 09 Mar 2010 13:00:56 GMT20100309010056Residual anaesthetic drugs in cannulae Signal27/11/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65333Fri, 27 Nov 2009 09:51:32 GMT20091127095132Fri, 27 Nov 2009 09:51:32 GMT20091127095132Tue, 09 Mar 2010 13:50:58 GMT20100309015058Recognition of compartment syndrome Signal27/11/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65331Fri, 27 Nov 2009 09:29:24 GMT20091127092924Fri, 27 Nov 2009 09:29:24 GMT20091127092924Tue, 09 Mar 2010 12:49:42 GMT20100309124942Pressure ulcers under plaster casts Signal27/11/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65330Fri, 27 Nov 2009 09:18:58 GMT20091127091858Fri, 27 Nov 2009 09:18:58 GMT20091127091858Tue, 09 Mar 2010 13:09:05 GMT20100309010905Surgical safety can be improved through better understanding of incidents12/10/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=63054Thu, 08 Oct 2009 16:59:56 GMT20091008045956Thu, 08 Oct 2009 16:59:56 GMT20091008045956Mon, 19 Jul 2010 17:38:23 GMT20100719053823Oxygen safety in hospitals Rapid Response Report29/09/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=62811Tue, 29 Sep 2009 11:51:59 GMT20090929115159Tue, 29 Sep 2009 11:51:59 GMT20090929115159Tue, 02 Feb 2010 16:01:25 GMT20100202040125Poor quality of organs for transplant Signal24/09/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=62532Wed, 23 Sep 2009 18:17:17 GMT20090923061717Wed, 23 Sep 2009 18:17:17 GMT20090923061717Tue, 09 Mar 2010 11:53:16 GMT20100309115316Delayed diagnosis of testicular torsion Signal24/09/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=62524Wed, 23 Sep 2009 17:35:09 GMT20090923053509Wed, 23 Sep 2009 17:35:09 GMT20090923053509Tue, 09 Mar 2010 11:56:06 GMT20100309115606Actions that can make anticoagulant therapy safer: Work competences01/03/2007http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61790Thu, 10 Sep 2009 13:05:41 GMT20090910010541Thu, 10 Sep 2009 13:05:41 GMT20090910010541Mon, 05 Jul 2010 12:30:22 GMT20100705123022Actions that can make oral anticoagulant therapy safer: Information for patients and carers28/03/2007http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61777Thu, 10 Sep 2009 12:17:01 GMT20090910121701Thu, 10 Sep 2009 12:17:01 GMT20090910121701Mon, 05 Jul 2010 12:08:29 GMT20100705120829Avoiding wrong side burr holes-craniotomy11/12/2008http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59889Tue, 18 Aug 2009 21:10:54 GMT20090818091054Tue, 18 Aug 2009 21:10:54 GMT20090818091054Mon, 17 May 2010 09:46:51 GMT20100517094651Reducing dosing errors with opioid medicines04/07/2008http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59888Tue, 18 Aug 2009 21:10:52 GMT20090818091052Tue, 18 Aug 2009 21:10:52 GMT20090818091052Fri, 28 May 2010 16:28:45 GMT20100528042845Chest drains: risks associated with the insertion of chest drains01/05/2008http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59887Tue, 18 Aug 2009 21:10:50 GMT20090818091050Tue, 18 Aug 2009 21:10:50 GMT20090818091050Tue, 08 Sep 2009 16:36:12 GMT20090908043612Emergency support in surgical units: dealing with haemorrhage10/09/2007http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59873Tue, 18 Aug 2009 21:10:24 GMT20090818091024Tue, 18 Aug 2009 21:10:24 GMT20090818091024Mon, 04 Oct 2010 14:31:31 GMT20101004023131Reducing risk of harm from oral bowel cleansing solutions19/02/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59869Tue, 18 Aug 2009 21:10:18 GMT20090818091018Tue, 18 Aug 2009 21:10:18 GMT20090818091018Wed, 30 Sep 2009 19:50:41 GMT20090930075041Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur11/03/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59867Tue, 18 Aug 2009 21:10:15 GMT20090818091015Tue, 18 Aug 2009 21:10:15 GMT20090818091015Fri, 30 Oct 2009 12:35:29 GMT20091030123529WHO Surgical Safety Checklist26/01/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59860Tue, 18 Aug 2009 21:10:04 GMT20090818091004Tue, 18 Aug 2009 21:10:04 GMT20090818091004Fri, 01 Apr 2011 14:20:59 GMT20110401022059Never Events Framework 2009-1001/02/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59859Tue, 18 Aug 2009 21:10:02 GMT20090818091002Tue, 18 Aug 2009 21:10:02 GMT20090818091002Mon, 17 May 2010 09:48:55 GMT20100517094855Throat Packs28/04/2009http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59853Tue, 18 Aug 2009 21:09:46 GMT20090818090946Tue, 18 Aug 2009 21:09:46 GMT20090818090946Fri, 04 Sep 2009 15:15:09 GMT20090904031509Patient Safety Observatory Report 4: Safety in doses01/01/2007http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59822Tue, 18 Aug 2009 21:08:41 GMT20090818090841Tue, 18 Aug 2009 21:08:41 GMT20090818090841Tue, 02 Feb 2010 15:19:55 GMT20100202031955Actions that can make anticoagulant therapy safer: Alert and other information28/03/2007http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59814Tue, 18 Aug 2009 21:08:15 GMT20090818090815Tue, 18 Aug 2009 21:08:15 GMT20090818090815Wed, 08 Jun 2011 09:34:18 GMT20110608093418Reducing the risk of hyponatraemia when administering intravenous infusions to children28/03/2007http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59809Tue, 18 Aug 2009 21:07:57 GMT20090818090757Tue, 18 Aug 2009 21:07:57 GMT20090818090757Thu, 24 Jun 2010 10:29:00 GMT20100624102900Epidural injections and infusions28/03/2007http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59807Tue, 18 Aug 2009 21:07:48 GMT20090818090748Tue, 18 Aug 2009 21:07:48 GMT20090818090748Tue, 08 Sep 2009 16:56:57 GMT20090908045657Right patient, right blood: advice for safer blood transfusions09/11/2006http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59805Tue, 18 Aug 2009 21:07:39 GMT20090818090739Tue, 18 Aug 2009 21:07:39 GMT20090818090739Fri, 04 Mar 2011 14:54:35 GMT20110304025435High dose morphine and diamorphine injections25/05/2006http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59803Tue, 18 Aug 2009 21:07:32 GMT20090818090732Tue, 18 Aug 2009 21:07:32 GMT20090818090732Tue, 15 Sep 2009 17:22:02 GMT20090915052202Protecting patients who are neck breathers07/03/2005http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59793Tue, 18 Aug 2009 21:06:56 GMT20090818090656Tue, 18 Aug 2009 21:06:56 GMT20090818090656Fri, 04 Mar 2011 11:54:55 GMT20110304115455Establishing a standard crash call telephone number in hospitals24/02/2004http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59789Tue, 18 Aug 2009 21:06:35 GMT20090818090635Tue, 18 Aug 2009 21:06:35 GMT20090818090635Fri, 04 Mar 2011 14:37:45 GMT20110304023745Improving infusion device safety20/05/2004http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59788Tue, 18 Aug 2009 21:06:29 GMT20090818090629Tue, 18 Aug 2009 21:06:29 GMT20090818090629Fri, 12 Nov 2010 11:07:40 GMT20101112110740