HSSIB Patient Safety Investigations

31 Jan 2023 HSIB Legacy Published 2 recs 2 obs 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 …

8 Dec 2022 HSIB Legacy Published 3 obs 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 …

21 Oct 2022 HSIB Legacy Published 4 recs 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 …

20 Oct 2022 HSIB Legacy Published 3 recs 4 obs 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 …

20 Oct 2022 HSIB Legacy Published 3 recs 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 …

14 Oct 2022 HSIB Legacy Published 4 recs 2 obs 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 …

13 Oct 2022 HSIB Legacy Published 5 recs 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 …

12 Oct 2022 HSIB Legacy Published 1 rec 4 obs 2 prompts 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.

12 Oct 2022 HSIB Legacy Published 6 recs 9 obs 1 action 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 …

7 Oct 2022 HSIB Legacy Published 6 recs Lack of timely monitoring of patients with glaucoma

Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month suffer severe …

5 Oct 2022 HSIB Legacy Published 1 action Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response

This national intelligence report provides insight into a safety risk related to PPE requirements for care workers delivering homecare during the COVID-19 response.

29 Sep 2022 HSIB Legacy Published 2 recs 3 obs 3 actions NHS 111’s response to callers with Covid-19-related symptoms during the pandemic

The purpose of this investigation is to support improvements in the delivery of NHS 111 and other telephone triage services during a national healthcare emergency.

25 Aug 2022 HSIB Legacy Published 3 obs 1 action Management of preterm labour and birth of twins

Preterm birth is one of the main causes for under-five mortality (death) and disability worldwide. This investigation considers the existing knowledge and management of preterm …

15 Aug 2022 HSIB Legacy Published 6 recs 8 obs 1 action The use of an appropriate flush fluid with arterial lines

This patient safety investigation aims to understand the risks for patients associated with blood sampling from arterial line systems used in adult critical care.

14 Jul 2022 HSIB Legacy Published 1 rec 5 obs 4 actions Clinical investigation booking systems failures: written communications in community languages

This investigation looks at the safety risk of booking systems failures. We explore the use of paper and hybrid booking systems and the production of …

8 Jul 2022 HSIB Legacy Published 4 obs 1 action Administering high-strength insulin from a pen device in hospital

This patient safety investigation looks at administering insulin from a pen device in hospitals. In 2017 there were 260,000 people with diabetes in the UK …

5 Jul 2022 Published 1 rec 5 obs 2 actions Positive patient identification

We've undertaken several investigations where misidentification of patients has been an important part of a patient safety event. This national learning report collates findings and …

26 May 2022 HSIB Legacy Published 3 recs 5 obs Decontamination of surgical instruments

Detailed examination of how the risk of contamination is currently managed within NHS trusts. Our investigation identifies regulatory and assurance gaps, plus four safety recommendations …

29 Apr 2022 HSIB Legacy Published 2 recs Emergency neonatal blood transfusion at birth following acute blood loss during labour and/or delivery

his investigation looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. Delays in neonatal blood …

29 Apr 2022 HSIB Legacy Published 7 recs 3 obs 6 prompts Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June 2020

The number of intrapartum stillbirths referred to the Healthcare Safety Investigation Branch (HSIB) between April and the end of June 2020 increased compared to the …

29 Apr 2022 HSIB Legacy Published 1 rec 5 obs Wrong site surgery – wrong patient: invasive procedures in outpatient settings

This investigation looks at the risks involved in the correct identification of patients in outpatient departments. Correct identification is crucial to make sure they receive …

28 Apr 2022 HSIB Legacy Published 2 obs Unintentional overdose of morphine sulfate oral solution

In this investigation we share Len's story. He took an accidental overdose of morphine sulfate oral liquid while at home. We've made two safety observations, …

28 Apr 2022 HSIB Legacy Published A thematic analysis of HSIB's first 22 national investigations

HSIB has analysed its first 22 HSIB national investigations to identify the recurring patient safety themes and to explore the impact so far of the …

8 Apr 2022 HSIB Legacy Published 3 recs 3 obs 2 actions Suitability of equipment and technology used for continuous fetal heart rate monitoring

This national patient safety investigation looks into the suitability of equipment and technology used for continuous fetal heart rate monitoring during labour and birth.

8 Apr 2022 HSIB Legacy Published 7 recs 5 obs 3 actions 3 prompts Management of chronic asthma in children aged 16 years and under

Asthma is the most common lung disease in the UK. 1.1 million children are diagnosed with the condition. Our investigation looks at the risks involved …