Patient safety investigations

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A nurse holds the hands of a patient. You can't see their heads, the focus is on their arms.

Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare

published
Independent report published by the Health Services Safety Investigations Body and arm's-length body members of the Recommendations to Impact Collaborative Group.
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Published

  • Theme:

    Patient safety themes
Aerial view of a prison site in the English countryside.

Healthcare provision in prisons

published
We've analysed the patient safety issues frequently highlighted within prison healthcare to identify themes. Our team is visiting prisons across England to investigate emergency care, continuity of care and data sharing and IT. First report of three now published.
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Published

  • Theme:

    Emergency care, Communication and decision making, Continuity of care

  • Awaiting safety recommendation responses

Focus on the hand of a hospital patient laying on a bed. An IV cannula is inserted in a vein on the top of their hand.

Recognition of sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)

We have launched three investigations to help address patient safety risks associated with recognition of sepsis.
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Launched

  • Theme:

    Delayed diagnosis, Hospital care, Patient safety themes
A female nurse gives an older woman medical pills.

Medication related harm

Medication is the most common intervention for patients in the NHS. In the most serious cases, delayed and missed medication can cause catastrophic effects. We have launched three local investigations and one national investigation into medication related harm.
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Launched

  • Theme:

    Medication, Communication and decision making, Continuity of care
A young woman with a pained expression lies in an ambulance with her eyes closed while two paramedics treat her.

Pre-hospital interpretation of electrocardiograms (ECG) in ambulance services

We have launched two investigations to help address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST Elevated Myocardial Infarction (StEMI).
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Launched

  • Theme:

    Emergency care, Cardiac
A young girl with an unhappy look on her face lies on her side in a hospital bed, hugging her teddy.

Keeping children and young people with mental health needs safe: the design of the paediatric ward

published
This investigation looks at the risk factors associated with the design of paediatric wards in acute hospitals for children and young people with mental health needs.
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Published

  • Theme:

    Mental health, Acute, Ward design

  • Awaiting safety recommendation responses

A sad looking woman lies awake on a hospital bed.

Patients at risk of self-harm: continuous observation

published
This investigation has found limited evidence that the current approach to continuous observation of adult patients at risk of self-harm on hospital wards is effective.
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Published

  • Theme:

    Hospital care

  • Awaiting safety recommendation responses

Two purple feeding pumps.

Nutrition management of acutely unwell patients in acute medical units

published
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.
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Published

  • Theme:

    Acute, Hospital care, Continuity of care
A nurse wearing scrubs prepares surgical instruments including swabs.

Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports

published
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.
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Published

  • Theme:

    Medical devices, Checking, Surgical

  • Awaiting safety recommendation responses

A tired hospital doctor rests his head on his hand as he sits at a desk.

Fatigue risk in healthcare and its impact on patient safety

Fatigue presents a potential significant risk to patient safety and staff wellbeing. In other safety-critical industries, fatigue is monitored and routinely considered as a potential contributory factor in safety incidents.
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Launched

  • Theme:

    NHS staff, Patient safety themes
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