Safety spotlight: Mothers with a learning disability
Maternity care should be responsive to every woman’s needs.
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Safety spotlight: Reviewing and actioning laboratory test results
MNSI has undertaken investigations where laboratory test results have not been reviewed and actioned.
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Safety Spotlight: Changes to the MNSI investigation report template
Safety spotlight
On 1st April 2024, six months after the transition to being hosted by the CQC, MNSI changed their investigation reports and process.
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Safety Spotlight: Maternal Deaths in the first trimester from Venous Thromboembolism (VTE)
Safety spotlight
MNSI has undertaken investigations of maternal deaths in the first trimester from venous thromboembolism (VTE)
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Safety Spotlight: Incomplete observations generating incorrect EWS
Safety spotlight
MNSI has investigated a number of patient safety events where an incomplete set of observations generated an early warning score (EWS) via an electronic patient record (EPR) system.
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Safety Spotlight: Prescribing and dispensing of low molecular weight heparin
Safety spotlight
Things MNSI recommend considering when prescribing low molecular weight heparin to avoid incorrect doses being dispensed.
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Safety Spotlight: Patient Ethnicity Data Collection
Safety spotlight
MNSI has found that inaccurate or missing recordings of a woman’s ethnicity have impacted her subsequent pathway of care.
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Safety Spotlight: Delayed escalation in abnormal CTGs
Safety spotlight
MNSI has completed a number of investigations in which time limits, as described in national guidance, have delayed categorisation of CTG recordings, resulting in delays in escalation.
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Safety Spotlight: Investigations into equipment and technology used for continuous fetal heart rate monitoring
Safety spotlight
MNSI has completed Investigations into equipment and technology used for continuous fetal heart rate monitoring.
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Safety Spotlight: Deaths from Anaphylaxis
Safety spotlight
MNSI is aware of maternal deaths from anaphylaxis.
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