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
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 …
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 …
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 …
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 …
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 …
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.
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 …
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.
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 …
Keeping children and young people with mental health needs safe: the design of the paediatric ward — HSSIB
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'.
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 …
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.
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 …
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 …
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.
Detection of jaundice in newborn babies
Jaundice is a common condition in newborn babies, with 1 in 20 requiring treatment. This national investigation explores safety issues associated with delayed diagnosis of …
The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period
Venous thromboembolism is the collective term for the formation of blood clots. Pregnant women could suffer a potentially fatal blood vessel blockage if their risk …
Failures in communication or follow-up of unexpected significant radiological findings
X-rays are the most common radiological examination. 22.9 million were carried out in the NHS in 2016/17. Failures in communication or follow-up of unexpected significant …
Management of chronic health conditions in prisons
Each day around 120 prisoners with ongoing medication needs are moved between prisons. This investigation identifies opportunities and remedies that could be applied across the …
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital
Research suggests that 237 million medication errors occur at some point in the medication process in England per year. When errors occur in prescribing high-risk …
The diagnosis of ectopic pregnancy
An estimated 12,000 women experience an ectopic pregnancy each year in the UK. Ectopic pregnancy occurs when the fertilised egg implants outside the uterus, usually …
Undetected button/coin cell battery ingestion in children
This investigation looks at the undetected ingestion of button/coin cell batteries in children. It follows a reference event where a child died following the unknown …
Electronic prescribing and medicines administration systems and safe discharge
We’ve identified a significant safety risk posed by poorly implemented electronic prescribing and medicines administration (ePMA) systems. An ePMA system supports the safe, effective, and …
HSIB’s local investigation pilot: shared learning for local healthcare systems
A summary of findings from our local investigation pilot applicable to local healthcare systems.
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.