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
Insulin: supporting safe administration in inpatient settings
This investigation examines risks to safety when patients who take insulin are admitted to acute hospitals. Insulin is a high risk medication and remains one …
Insulin: supporting safe self-administration for patients in the community with a mental health problem
This investigation explores risks to patient safety for patients in the community who self-administer insulin and who may be at increased risk of harm because …
Electronic patient record systems – risk from loss of functionality
We have launched an investigation that explores risks to patient safety where access to, the use of, or functionality of electronic patient record (EPR) systems …
Patient care in temporary care environments
This investigation explores the management of patient safety risks associated with using temporary care environments, often referred to as ‘corridor care’ and ‘temporary escalation spaces’.
Electronic patient record (EPR) systems – thematic review
We have completed a thematic review of 50 HSSIB reports to identify specific patient safety issues and learning related to electronic patient record (EPR) systems. …
The use of lithium for bipolar disorder
Around 1 in 50 adults experience bipolar disorder within their lives. Whilst the number of people with bipolar disorder has remained consistent over time the …
12-lead electrocardiograms (ECGs) in ambulance services
These two investigations will help to address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST Elevated Myocardial Infarction …
12-lead electrocardiograms (ECGs) in ambulance services: diagnosis of suspected ST elevation myocardial infarction (STEMI) — HSSIB
This is the second investigation to help to address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST Elevated …
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
This report shares our learning about patient safety incident investigation under the Patient Safety Incident Response Framework (PSIRF). It's intended for national and local organisations …
Safety issues for people experiencing a mental health crisis who come into contact with urgent and emergency care services
Mental health crisis describes when a person feels at breaking point and where they need urgent help. We have launched two investigations that explore the …
An exploratory review of maternity and neonatal services
This report is a summary of information HSSIB collected during an exploratory review of maternity and neonatal services in spring 2025. This exploratory review involved …
Medication not given: discharge from an acute hospital to the community
This is the third investigation report into medication related harm. Medication is the most common intervention for patients in the NHS. In the most serious …
Healthcare provision in prisons: data sharing and IT
This is the third of a series of HSSIB reports on the theme of healthcare provision in prisons. The first report explored emergency care response, …
Workforce and patient safety
The workforce challenges faced by the NHS in England present a risk to patient safety and staff wellbeing. We've undertaken five investigations to consider how …
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
This is the fifth investigation report that considers how working conditions in the NHS can be optimised to support patient safety, while maintaining and improving …
Sepsis: a patient with abdominal pain
This is the third investigation report we have published to help address patient safety risks associated with sepsis. To support NHS organisations in investigating these …
Sepsis: a patient with a urine infection
This is the second investigation report we have published to help address patient safety risks associated with sepsis. To support NHS organisations in investigating these …
Sepsis: a patient with diabetes and a foot infection
This is the first investigation report we have published to help address patient safety risks associated with sepsis. To support NHS organisations in investigating these …
Mental health inpatient settings
This series of patient safety investigations look at mental health inpatient settings. They were directed by the Secretary of State for Health and Social Care. …
Mental health inpatient settings: overarching report of investigations directed by the Secretary of State for Health and Social Care
This series of investigations was announced by the Secretary of State for Health and Social Care in June 2023, launched in January 2024 and completed …
The impact of staff fatigue on patient safety
Staff fatigue contributes directly and indirectly to patient harm. Yet fatigue is not routinely considered in patient safety event reporting or learning reviews. We share …
Workforce and patient safety: primary and community care co-ordination for people with long-term conditions
This is the fourth of five investigation reports that consider how working conditions in the NHS can be optimised to support patient safety, while maintaining …
12-lead electrocardiograms (ECGs) in ambulance services: paramedic education, training and competence
This is the first of two investigations to help address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST …
Medication not given: anticoagulation before and after a procedure
This is the second of three locality-based patient safety investigation reports, which presents the findings of an investigation into a patient safety event at an …
Safety management
This investigation considers how safety management is coordinated and integrated across the healthcare system. It looks at accountability beyond organisational boundaries and involving NHS staff …
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.