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
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 …
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 …
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 …
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 …
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.
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 …
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.
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 …
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.
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.
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 …
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 …
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 …
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 …
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 …
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.