HSSIB Patient Safety Investigations

Acute medical units (AMUs) are the first point of entry for patients referred to hospital as an emergency by their GP and those who require admission from emergency departments. This investigation seeks to support improvements in identification and management of nutritional needs in AMUs.

Retained swabs are classed as Never Events. Data shows there has been 11-23 retained swab incidents per year since 2015. The investigation was launched after we examined the case of a patient who had two swabs left in her chest following serious heart surgery.

This investigation explores intubation of patients with difficult airways. There are no standards for how an anticipated difficult airway is managed. Failure to provide an adequate airway can result in brain injury or death.

While some GP practices in England operate a formalised system of continuity of care, many do not. This investigation explores the safety risk associated with the lack of a system of continuity of care within GP practices.

Ambulatory infusion pumps are small, battery powered medical devices. This investigation aims to improve patient safety by supporting healthcare staff in the safe use of ambulatory (portable) infusion pumps.

This investigation explores the care that people with learning disabilities receive in NHS hospitals. It looks at provision of healthcare to adults with learning disabilities within acute hospital settings.

Safety management systems are an organised approach to managing safety which are widely used in different industries. This national learning report looks at what could be achieved by further adopting this approach in healthcare.

This investigation looks at the risks for patients with sickle cell disease when they undergo invasive procedures in hospital. It explores how hospital specialities can ensure that patients with sickle cell disease are prepared for procedures which could put them at risk of a sickle cell crisis.

This national investigation looks at variations in delivery of palliative care services to adults in England, by the NHS, charities and private sector.

This investigation explores issues around patient handover to emergency care. Patients who wait in ambulances at an emergency department are at potential risk of coming to harm due to deterioration or not being able to access timely and appropriate treatment.

Almost 30,000 people in the UK currently receive dialysis. This investigation looks at associated patient safety risks in operating theatres, and packaging of vascular grafts.

Sickle cell disease is the name for a group of inherited health conditions that affect the red blood cells. It affects approximately 15,000 people in the UK. This investigation looks at the risks for patients with sickle cell disease when they are treated with morphine for a sickle cell crisis.

This investigation explores the challenges for clinicians associated with making the clinical judgement as to whether an injury is accidental or not. Please note that due to the subject matter of this report it contains details which some readers may find distressing.

This investigation aims to improve patient safety by supporting healthcare staff in the safe use of central venous catheters to access a patient’s blood supply.

In 2018, there were 1,306 suicides in England by people who had been in contact with mental health services in the previous 12 months. This investigation emphasises that NHS trusts should move away from standardised scoring tools that categorise a patient as high, medium or low risk, as they are a poor predictor of repeated self-harm or future suicide.

Despite a wealth of national guidance, risk assessments in the maternity pathway remain a significant challenge. This national learning report highlights the need for a personalised and dynamic risk assessment approach.

This investigation explores the challenges NHS hospital staff face when trying to access key information about their patients, at the patient bedside.

Jaundice is a common condition in newborn babies, with 1 in 20 requiring treatment. This national investigation explores safety issues associated with delayed diagnosis of jaundice in newborn babies.

Venous thromboembolism is the collective term for the formation of blood clots. Pregnant women could suffer a potentially fatal blood vessel blockage if their risk is not properly assessed during pregnancy and the first six weeks after birth.

X-rays are the most common radiological examination. 22.9 million were carried out in the NHS in 2016/17. Failures in communication or follow-up of unexpected significant radiological findings is a nationally recognised patient safety risk.

Research suggests that 237 million medication errors occur at some point in the medication process in England per year. When errors occur in prescribing high-risk medications for older patients with multiple medical problems, there is a significant risk of serious harm. High-risk medicines are those which risk significant patient harm or death when used in error, such as warfarin.

Each day around 120 prisoners with ongoing medication needs are moved between prisons. This investigation identifies opportunities and remedies that could be applied across the system to reduce the risk of prisoners with long term, chronic conditions being moved without crucial medication.

An estimated 12,000 women experience an ectopic pregnancy each year in the UK. Ectopic pregnancy occurs when the fertilised egg implants outside the uterus, usually in the Fallopian tube. If it’s left untreated, it can rupture and cause internal bleeding.

This investigation looks at the undetected ingestion of button/coin cell batteries in children. It follows a reference event where a child died following the unknown and undetected ingestion of a coin cell battery.

A summary of findings from our local investigation pilot applicable to local healthcare systems.