Source · Patient safety investigations
HSSIB Patient Safety Investigations
150 investigations
339 recommendations
279 observations
70 actions
262 learning prompts
19 improvement areas
8 scope items
294/339 responded
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.
Key findings
HSSIB has completed 150 patient safety investigations,
producing 339 safety recommendations, 279 observations
and 70 safety actions, alongside 262 local learning prompts, 19 areas of improvement, and 8 scope items.
87% of safety recommendations have received a published response.
Investigations
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 …
15 Apr 2021
HSIB Legacy
Published
3 obs
8 prompts
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
We have carried out a themed review of our maternal death investigations during the coronavirus (COVID-19) pandemic.
15 Apr 2021
HSIB Legacy
Published
2 recs
3 obs
Medicine omissions in learning disability secure units
This healthcare safety investigation looks at patients on learning disability secure units who do not receive medicines that have been prescribed to them.
13 Apr 2021
HSIB Legacy
Published
5 recs
7 obs
Weight-based medication errors in children
Studies show that prescribing errors are the most frequent type of medication error in children’s inpatient settings. This investigation looks at the risks involved when …
15 Mar 2021
HSIB Legacy
Published
1 rec
Piped supply of medical air and oxygen
This investigation focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to …
24 Jan 2019
HSIB Legacy
Published
2 recs
Transfer of critically ill adults
This investigation looks at the transfer of critically ill adults. It has previously been referred to as 'Cardiac and vascular pathways', but the original investigation …
23 Nov 2018
HSIB Legacy
Published
4 recs
Provision of mental health care to patients presenting at the emergency department
In England, it is estimated that 5% of all hospital emergency department attendances are primarily due to mental ill-health. This investigation reinforces the need for …
21 Jun 2018
HSIB Legacy
Published
4 recs
Implantation of wrong prostheses during joint replacement surgery
This investigation relates to the implantation of the wrong prostheses (artificial body parts) during joint replacement surgery - a surgical never event. A never event …