HSSIB Patient Safety Investigations

23 May 2024 HSIB Legacy Published 1 rec Keeping children and young people with mental health needs safe: the design of the paediatric ward

This investigation looks at the risk factors associated with the design of paediatric wards in acute hospitals for children and young people with mental health …

23 May 2024 HSIB Legacy Published 3 recs Keeping children and young people with mental health needs safe: the design of the paediatric ward — HSSIB 8 May 2024 Published 2 recs 14 prompts Patients at risk of self-harm: continuous observation

This investigation has found limited evidence that the current approach to continuous observation of adult patients at risk of self-harm on hospital wards is effective.

25 Apr 2024 Published 5 prompts Nutrition management of acutely unwell patients in acute medical units

Acute medical units (AMUs) are the first point of entry for patients referred to hospital as an emergency by their GP and those who require …

16 Apr 2024 Published 3 recs 4 obs Investigation report: Retained swabs following invasive procedures

Full online version of the Health Services Safety Investigations Body (HSSIB) report 'Retained swabs following invasive procedures: themes identified from a review of NHS serious …

16 Apr 2024 Published 1 rec Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports

Retained swabs are classed as Never Events. Data shows there has been 11-23 retained swab incidents per year since 2015. The investigation was launched after …

14 Mar 2024 Published 2 recs 1 obs 6 prompts Temporary staff – involvement in patient safety investigations

Full online version of the Health Services Safety Investigations Body (HSSIB) investigation report 'Workforce and patient safety: temporary staff - involvement in patient safety investigations'.

25 Jan 2024 Published 4 recs 3 obs 1 action Advanced airway management in patients with a known complex disease

This investigation explores intubation of patients with difficult airways. There are no standards for how an anticipated difficult airway is managed. Failure to provide an …

7 Dec 2023 Published 1 rec 1 obs Interim report: Retained swabs following invasive procedures

Full online version of the Health Services Safety Investigations Body (HSSIB) interim report 'Retained swabs following invasive procedures: themes identified from a review of NHS …

30 Nov 2023 Published 2 recs 1 obs Continuity of care: delayed diagnosis in GP practices

While some GP practices in England operate a formalised system of continuity of care, many do not. This investigation explores the safety risk associated with …

15 Nov 2023 Published 3 recs 3 obs Risks to medication delivery using ambulatory infusion pumps: design and usability in inpatient settings

Ambulatory infusion pumps are small, battery powered medical devices. This investigation aims to improve patient safety by supporting healthcare staff in the safe use of …

2 Nov 2023 Published 4 recs 3 obs 2 actions Caring for adults with a learning disability in acute hospitals

This investigation explores the care that people with learning disabilities receive in NHS hospitals. It looks at provision of healthcare to adults with learning disabilities …

18 Oct 2023 Published 2 recs 1 obs Safety management systems: an introduction for healthcare

Safety management systems are an organised approach to managing safety which are widely used in different industries. This national learning report looks at what could …

28 Sep 2023 HSIB Legacy Published 2 recs 2 obs Invasive procedures in patients with sickle cell disease

This investigation looks at the risks for patients with sickle cell disease when they undergo invasive procedures in hospital. It explores how hospital specialities can …

28 Sep 2023 HSIB Legacy Published 3 recs 5 actions Variations in the delivery of palliative care services to adults

This national investigation looks at variations in delivery of palliative care services to adults in England, by the NHS, charities and private sector.

24 Aug 2023 HSIB Legacy Published 2 recs 1 obs Harm caused by delays in transferring patients to the right place of care

This investigation explores issues around patient handover to emergency care. Patients who wait in ambulances at an emergency department are at potential risk of coming …

27 Jul 2023 HSIB Legacy Published 4 recs 3 obs The selection and insertion of vascular grafts in haemodialysis patients

Almost 30,000 people in the UK currently receive dialysis. This investigation looks at associated patient safety risks in operating theatres, and packaging of vascular grafts.

22 Jun 2023 HSIB Legacy Published 1 rec Management of sickle cell crisis

Sickle cell disease is the name for a group of inherited health conditions that affect the red blood cells. It affects approximately 15,000 people in …

25 May 2023 HSIB Legacy Published 1 obs Keeping children and young people with mental health needs safe: the design of the paediatric ward — HSSIB 27 Apr 2023 HSIB Legacy Published 1 rec 4 obs Investigation report: Clinical investigation booking systems failures - written communications in community languages

Full online version of the Healthcare Safety Investigation Branch (HSIB) report 'Clinical investigation booking systems failures - written communications in community languages'.

13 Apr 2023 HSIB Legacy Published 2 recs 3 obs 3 prompts Non-accidental injuries in infants attending the emergency department

This investigation explores the challenges for clinicians associated with making the clinical judgement as to whether an injury is accidental or not. Please note that …

30 Mar 2023 HSIB Legacy Published 3 recs 4 obs 2 actions Safety risk of air embolus associated with central venous catheters used for haemodialysis treatment

This investigation aims to improve patient safety by supporting healthcare staff in the safe use of central venous catheters to access a patient’s blood supply.

23 Mar 2023 HSIB Legacy Published 4 recs 4 obs 1 action Care delivery within community mental health teams

In 2018, there were 1,306 suicides in England by people who had been in contact with mental health services in the previous 12 months. This …

2 Mar 2023 HSIB Legacy Published 3 prompts Assessment of risk during the maternity pathway

Despite a wealth of national guidance, risk assessments in the maternity pathway remain a significant challenge. This national learning report highlights the need for a …

2 Feb 2023 HSIB Legacy Published 8 recs 3 obs Access to critical patient information at the bedside

This investigation explores the challenges NHS hospital staff face when trying to access key information about their patients, at the patient bedside.