HSSIB Patient Safety Investigations

We’ve identified a significant safety risk posed by poorly implemented electronic prescribing and medicines administration (ePMA) systems. An ePMA system supports the safe, effective, and cost-effective use of medicines from a patient’s admission to hospital until their discharge.

Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month suffer severe or permanent sight loss as a result of the delays.

This national intelligence report provides insight into a safety risk related to PPE requirements for care workers delivering homecare during the COVID-19 response.

The purpose of this investigation is to support improvements in the delivery of NHS 111 and other telephone triage services during a national healthcare emergency.

Preterm birth is one of the main causes for under-five mortality (death) and disability worldwide. This investigation considers the existing knowledge and management of preterm labour and birth of twins.

This patient safety investigation aims to understand the risks for patients associated with blood sampling from arterial line systems used in adult critical care.

This patient safety investigation looks at administering insulin from a pen device in hospitals. In 2017 there were 260,000 people with diabetes in the UK who experienced a medication error.

We've undertaken several investigations where misidentification of patients has been an important part of a patient safety event. This national learning report collates findings and identifies how these misidentifications have been able to happen.

Detailed examination of how the risk of contamination is currently managed within NHS trusts. Our investigation identifies regulatory and assurance gaps, plus four safety recommendations to address them.

his investigation looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. Delays in neonatal blood transfusion emerged as a safety risk from investigations carried out under our maternity investigation programme.

The number of intrapartum stillbirths referred to the Healthcare Safety Investigation Branch (HSIB) between April and the end of June 2020 increased compared to the same time in the previous year. The data initiated an HSIB national learning report which explored the findings from our maternity investigations during this time.

This investigation looks at the risks involved in the correct identification of patients in outpatient departments. Correct identification is crucial to make sure they receive the right clinical procedure.

In this investigation we share Len's story. He took an accidental overdose of morphine sulfate oral liquid while at home. We've made two safety observations, relevant to manufacturers of morphine liquids, and to encourage participation in HSIB investigations.

HSIB has analysed its first 22 HSIB national investigations to identify the recurring patient safety themes and to explore the impact so far of the 85 recommendations we have made to address them. The work was undertaken after it was recognised that similar issues were arising in our investigations, even when investigations were focused on different clinical fields.

This national patient safety investigation looks into the suitability of equipment and technology used for continuous fetal heart rate monitoring during labour and birth.

Asthma is the most common lung disease in the UK. 1.1 million children are diagnosed with the condition. Our investigation looks at the risks involved in the management of children aged 16 years and under diagnosed with asthma.

Cauda equina syndrome (CES) is a rare and severe type of spinal stenosis. If CES is not diagnosed and treated in a timely way it can lead to permanent incontinence, sexual dysfunction and even paralysis.

This investigation explores the care of patients who present to child and adolescent mental health services (CAMHS) with questions about their gender identity and are referred to specialist gender dysphoria services.

This investigation looks at the timely recognition and treatment of suspected pulmonary embolism (PE). A person suffering from a PE (a clot in the lung) requires urgent treatment to reduce the chance of significant harm or death.

This national investigation looks into the safety risk of delayed diagnosis of lung cancer. Specifically, the investigation explores delays in patients being seen in primary care and who had a chest X-ray that had not detected cancer.

Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.

This investigation looks at the delivery of safe care to NHS-funded patients undergoing surgery within independent (private) hospitals.

Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.

Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.

This national investigation aims to improve patient safety for women and pregnant people waiting for an ambulance because of a pregnancy issue.