HSSIB Patient Safety Investigations

8 Apr 2022 HSIB Legacy Published 5 recs 4 obs 2 actions 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 …

6 Apr 2022 HSIB Legacy Published 1 rec 4 obs 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 …

29 Mar 2022 HSIB Legacy Published 3 recs 6 obs 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) …

24 Mar 2022 HSIB Legacy Published 3 recs 1 obs 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 …

23 Mar 2022 HSIB Legacy Published 3 recs 1 obs 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 …

23 Mar 2022 HSIB Legacy Published 6 recs 2 obs 1 action 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.

22 Mar 2022 HSIB Legacy Published 3 recs 4 obs 3 actions 3 prompts 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 …

22 Mar 2022 HSIB Legacy Published 6 recs 4 obs 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 …

21 Mar 2022 HSIB Legacy Published 2 recs 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.

18 Mar 2022 HSIB Legacy Published 3 obs 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).

16 Mar 2022 HSIB Legacy Published 5 recs 6 obs Recognition of the acutely ill infant

We were notified of a three-month-old infant who was admitted to hospital and discharged four hours later. The infant was re-admitted less than four hours …

30 Jan 2022 HSIB Legacy Published 1 rec Administering a wrong site nerve block

This investigation seeks to identify opportunities and systemic remedies to reduce the risk of wrong site anaesthetic nerve blocks occurring. Anaesthetic nerve blocks are injections …

20 Nov 2021 HSIB Legacy Published 1 prompt Treating Covid-19 patients using continuous positive airway pressure (CPAP) outside of a critical care unit

This investigation looked into the safety risk of treating patients with coronavirus (COVID-19) with Continuous Positive Airway Pressure Ventilation (CPAP) outside of critical care units.

16 Jun 2021 HSIB Legacy Published 3 recs Management of acute onset testicular pain

This investigation looks at delayed diagnosis of testicular torsion. This is a condition where the testicle twists, cuts off the blood supply and results in …

16 Jun 2021 HSIB Legacy Published 2 recs Recognising and responding to critically unwell patients

Problems in recognising and responding to deteriorating patients continues to be a major source of severe harm and preventable death in hospitals. Previous research has …

15 Jun 2021 HSIB Legacy Published 7 recs 5 obs 10 actions Potential under-recognised risk of harm from the use of propranolol

This patient safety investigation explores the under recognised toxicity of propranolol in overdose. Propranolol is used to treat medical conditions including migraine, cardiovascular problems and …

15 Jun 2021 HSIB Legacy Published 6 recs 6 prompts Transition from child and adolescent mental health services to adult mental health services

We investigate how young people are supported in the transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) when …

11 Jun 2021 HSIB Legacy Published 1 rec 6 prompts Wrong patient details on blood sample

Wrong blood in tube (WBIT) incidents can occur when blood samples are taken from patients and are either miscollected (blood is taken from the wrong …

11 Jun 2021 HSIB Legacy Published 1 rec Design and safe use of portable oxygen systems

NHS Improvement issued a patient safety alert on medical devices in January 2018. It highlighted 400 incidents - including six deaths - over three years …

7 Jun 2021 HSIB Legacy Published 1 rec 1 obs Detection of retained vaginal swabs and tampons following childbirth

Retained vaginal swabs are classed as a ‘never event’. A never event is a serious incident that is entirely preventable. Data compiled by NHS England/Improvement …

4 Jun 2021 HSIB Legacy Published 4 recs Inadvertent administration of an oral liquid into a vein

This investigation emphasises that complex and fragmented medicine safety processes are putting patients across the country at risk. The report puts forward safety recommendations aimed …

2 Jun 2021 HSIB Legacy Published 2 recs 3 obs 1 action Delayed recognition of acute aortic dissection

Acute aortic dissection is a relatively rare but life-threatening condition. It requires rapid recognition and urgent treatment in a specialist centre. The symptoms and signs …

28 May 2021 HSIB Legacy Published 3 prompts Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection

In February 2020 we published a national learning report to highlight the themes emerging from the initial investigations carried out as part of our maternity …

19 May 2021 HSIB Legacy Published 4 recs 4 obs 3 actions Oxygen issues during the COVID-19 pandemic

There has been an increased demand for oxygen gas in hospital wards during the Covid-19 pandemic. Covid-19 can cause severe inflammation of the lungs affecting …

19 May 2021 HSIB Legacy Published 1 action Early warning scores to detect deterioration in COVID-19 inpatients

This national intelligence report provides insight into a safety risk when using early warning scores to detect deterioration in patients with coronavirus (COVID-19) on general …