Source · Patient safety investigations
HSSIB Patient Safety Investigations
157 investigations
340 recommendations
279 observations
70 actions
262 learning prompts
23 improvement areas
8 scope items
302/340 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 157 patient safety investigations,
producing 340 safety recommendations, 279 observations
and 70 safety actions, alongside 262 local learning prompts, 23 areas of improvement, and 8 scope items.
89% of safety recommendations have received a published response.
Investigations
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 …