Source · Patient safety investigations
HSSIB Patient Safety Investigations
HSSIB conducts independent investigations into patient safety concerns across England's NHS, producing safety recommendations directed at named organisations. Data sourced from hssib.org.uk.
165 investigations349 recommendations indexed307 recommendations with responses
Investigations
Medication safety in care homes for older people
These local investigations explore how medication is managed in everyday practice, while recognising that care homes are people's homes and should support residents' choices, preferences …
Preventing perinatal mental health deaths: recognition, access and support
The Health Services Safety Investigations Body (HSSIB) is investigating how perinatal mental health concerns are recognised, assessed and supported during pregnancy and the year after …
Improving surgical safety through reporting, monitoring and learning
This investigation will focus on current monitoring systems and how the information they collect is shared and effectively used to help identify potential issues and …
Placenta Accreta Spectrum: understanding the barriers to timely diagnosis and care
We have launched an investigation to understand the barriers to timely diagnosis and care for women with placenta accreta spectrum (PAS). PAS is a life-threatening …
Mental health crisis care: care of patients in emergency departments — HSSIB
People in mental health crisis may need to be assessed for admission to a mental health hospital in line with the Mental Health Act 1983. …
Electronic patient record systems – electronic referrals for ongoing care
We have launched an investigation that explores risks to patient safety where electronic patient record (EPR) systems, introduced to support referrals for patient care, have …
Insulin: supporting safe self-administration for patients in the community with a learning disability
This report is the third in a series considering the self-administration of insulin by people with diabetes mellitus (diabetes) in community settings. Each report in …
Insulin: supporting safe self-administration in vulnerable patient groups in the community
This series of reports explores risks to patient safety for patients in the community who self-administer insulin and who may be at increased risk of …
The use of Ambient Voice Technology in hospitals
Adoption of Ambient Voice Technology (AVT) is accelerating while the safety implications are not fully understood. This investigation will focus on acute adult secondary care …
Care of children waiting for access to child health community services
There is widespread concern about child health community services presenting some of the longest waits in the healthcare system and these delays contributing to lasting …
Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)
These three investigations provide examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF). PSIRF sets out the NHS’s approach to developing …
Mental health: physical health deterioration while under the care of a low secure unit
HSSIB has modelled an approach to investigating patient safety events under the NHS Patient Safety Incident Response Framework (PSIRF). This report considers the care of …
Deterioration in adults with a learning disability in primary care
This investigation will explore the care adults with a learning disability receive in primary care when their health is deteriorating or they have new symptoms. …
Deterioration in adults with a learning disability in the community
This investigation will explore the care adults with a learning disability receive in primary care when their health is deteriorating or they have new symptoms. …
Identifying and supporting mental health problems in children via general practice
We have launched an investigation exploring how mental health problems in children are identified and supported via general practice. This is due to widespread concern …
Safety accountability and oversight thematic review
This thematic review considers safety accountability and oversight across all HSIB and HSSIB investigations to date. It provides an opportunity to identify which patient groups …
Online prescribing: challenges and opportunities to improve patient safety
This investigation looks at the complex regulatory landscape around independent online prescribing and challenges sharing patient information between the NHS and independent online prescribing services.
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
We've identified patient safety risks across regional care pathways, linked to unclear roles, limited oversight and inconsistent information sharing which can limit how risks are …
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
This is the fourth investigation looking at medication related harm, exploring the safety issues associated with medication not given. Medication is the most common intervention …
Medication related harm
Medication is the most common intervention for patients in the NHS. In the most serious cases, delayed and missed medication can cause catastrophic effects. We …
Insulin: supporting safe self-administration for patients in the community with a disability
Diabetes is one of the most common chronic diseases in England and the number of people with the condition is on the increase. It is …
Mental health: attempted suicide while under the care of community services
The is the first of three investigations to provide examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF). PSIRF sets out …
Mental health crisis care: legislative challenges in emergency departments
This is the first of two investigations that explore the patient safety issues associated with care pathways for people experiencing a mental health crisis who …
Healthcare provision in prisons
We've analysed the patient safety issues frequently highlighted within prison healthcare to identify themes. Our four investigation reports in this series span emergency care response, …
Healthcare provision in prisons: needs assessments and disability access
This is the final report that covers needs assessments and physical disability access, which were identified as patient safety risk areas during the investigation. Prison …
165 investigations
349 recommendations
284 observations
70 actions
264 learning prompts
23 improvement areas
4 scope items
307/349 responded
Indexed output types
Read the chart values
| Output type | Items |
|---|---|
| Safety recommendations | 349 |
| Observations | 284 |
| Safety actions | 70 |
| Learning prompts | 264 |
| Areas of improvement | 23 |
| Investigation scope | 4 |
Key findings
This collection contains 165 patient safety investigations,
producing 349 safety recommendations, 284 observations
and 70 safety actions, alongside 264 local learning prompts, 23 areas of improvement, and 4 scope items.
88% of safety recommendations have received a published response.