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
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 …
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 …
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.
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 …
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 …
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 …
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 …
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 …
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 …
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 …
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 …
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 …
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 …
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 …
Giving families a voice: HSIB’s approach to patient and family engagement during investigations
This national learning report highlights the themes emerging from our contact with families during our patient safety investigations. Our national learning reports describe common themes …
Neonatal collapse alongside skin-to-skin contact
In March 2020 we published a national learning report to highlight the themes emerging from the initial investigations carried out as part of our maternity …
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 …
Summary of themes arising from the HSIB maternity programme
This national learning report highlights the themes emerging from the initial investigations carried out as part of our maternity investigation programme. It looks at maternity …
Insertion of an incorrect intraocular lens
Cataract removal and implantation of an artificial lens is the most common surgical procedure undertaken by the NHS. Insertion of an incorrect intraocular lens was …
Undiagnosed cardiomyopathy in a young person with autism
People with additional needs receiving care in hospital may require adjustments to promote their safety and improve their experience of care. This investigation seeks to …
Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke
Every year in the UK over 100,000 people have a stroke. Patients who are admitted to hospital for any reason, including stroke, are assessed for …
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
This prospective patient safety investigation looks at how hospitals can minimise the likelihood of patients catching coronavirus (COVID-19) on acute hospital wards.
Unplanned delayed removal of ureteric stents
This investigation relates to patients with kidney stones who have had a ureteric stent inserted and where the stent is left in longer than planned.
Emergency response to heart attack
This investigation looks at the emergency response to heart attack across the NHS in England.
Residual drugs in intravenous cannulae and extension lines
This patient safety investigation looks at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines.
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.