HSSIB Patient Safety Investigations

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 …

19 May 2021 HSIB Legacy Published 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 …

19 May 2021 HSIB Legacy Published 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 …

18 May 2021 HSIB Legacy Published 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 …

7 May 2021 HSIB Legacy Published 3 recs 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 …

6 May 2021 HSIB Legacy Published 8 recs 1 obs 2 actions 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 …

5 May 2021 HSIB Legacy Published 1 rec 3 obs 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 …

4 May 2021 HSIB Legacy Published 8 recs 6 obs 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.

4 May 2021 HSIB Legacy Published 4 recs 2 obs 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.

30 Apr 2021 HSIB Legacy Published 3 recs 3 obs Emergency response to heart attack

This investigation looks at the emergency response to heart attack across the NHS in England.

30 Apr 2021 HSIB Legacy Published 2 recs 3 obs 15 prompts 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.

29 Apr 2021 HSIB Legacy Published 2 recs Outpatient appointments intended but not booked after inpatient stays

We identified a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient stay. If a patient does not receive …

27 Apr 2021 HSIB Legacy Published 3 recs 1 action 4 prompts Wrong site surgery – wrong tooth extraction

Wrong tooth extraction is the most common form of wrong site surgery reported over the past five years. This is classed as a Never Event …

26 Apr 2021 HSIB Legacy Published 1 rec Delays to intrapartum intervention once fetal compromise is suspected

We have identified a safety risk in maternity care relating to delays to intrapartum intervention once fetal compromise is suspected. The term intrapartum refers to …

26 Apr 2021 HSIB Legacy Published 1 rec 5 obs 6 prompts Procurement, usability and adoption of ‘smart’ infusion pumps

Although the aim of smart infusion pumps is to improve patient safety, the technology can introduce new risks. This investigation focused on understanding the challenges …

22 Apr 2021 HSIB Legacy Published 2 obs Support for staff following patient safety incidents

This national learning report explores HSIB’s insights into how NHS staff are supported by their trusts following patient safety incidents, with a focus on good …

22 Apr 2021 HSIB Legacy Published 5 recs 7 obs 3 actions Placement of nasogastric tubes

This investigation looks at nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice.

20 Apr 2021 HSIB Legacy Published 3 recs 1 obs 15 prompts Never events: analysis of HSIB's national investigations

This national learning report analyses the findings of the investigations previously carried out by HSIB concerning incidents classified as never events.

19 Apr 2021 HSIB Legacy Published 1 rec Severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia

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 …