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
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 …
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.
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.
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 …
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.
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 …
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 …
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 …
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 …
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 …
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 …
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 …
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, …
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 …
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.
Timely detection and treatment of cauda equina syndrome
Cauda equina syndrome (CES) is a rare and severe type of spinal stenosis. If CES is not diagnosed and treated in a timely way it …
Provision of care for children and young people when accessing specialist gender dysphoria services
This investigation explores the care of patients who present to child and adolescent mental health services (CAMHS) with questions about their gender identity and are …
Clinical decision making: diagnosis of pulmonary embolism in emergency departments
This investigation looks at the timely recognition and treatment of suspected pulmonary embolism (PE). A person suffering from a PE (a clot in the lung) …
Missed detection of lung cancer on chest X-rays of patients being seen in primary care
This national investigation looks into the safety risk of delayed diagnosis of lung cancer. Specifically, the investigation explores delays in patients being seen in primary …
Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to emergency care
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as …
Surgical care of NHS patients in independent hospitals
This investigation looks at the delivery of safe care to NHS-funded patients undergoing surgery within independent (private) hospitals.
Local integrated investigation pilot 1: Incorrect patient identification
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as …
Local integrated investigation pilot 2: Incorrect patient details on handover
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as …
Maternity pre-arrival instructions by 999 call handlers
This national investigation aims to improve patient safety for women and pregnant people waiting for an ambulance because of a pregnancy issue.
Unintentional overdose of paracetamol in adults with low bodyweight
This investigation explores the prescription of oral paracetamol in adult inpatients who, on admission to hospital, have low bodyweight (less than 50kg).
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.