Patient safety investigations

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An older male patient talks to a GP, sat either side of a desk in a consulting room.

Continuity of care: Delayed diagnosis in GP practices

published
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.
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Published

  • Theme:

    Delayed diagnosis, Continuity of care, Primary care

  • Awaiting safety recommendation responses

A nurse speaks to a cancer patient.

Risks to medication delivery using ambulatory infusion pumps: design and usability in inpatient settings

published
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.
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Published

  • Theme:

    Medical devices

  • Awaiting safety recommendation responses

A nurse helps an older male patient to stand up from his hospital bed.

Caring for adults with a learning disability in acute hospitals

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

  • Theme:

    Hospital care, Learning disabilities

  • Awaiting safety recommendation responses

A space shuttle launches into a blue sky.

Safety management systems: an introduction for healthcare

published
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.
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Published

  • Theme:

    Patient safety themes, NHS staff, Patient and family

  • Awaiting safety recommendation responses

A district nurse cares for an elderly man with a head injury in his living room at home.

Workforce and patient safety

The workforce challenges faced by the NHS in England present a significant risk to patient safety and staff wellbeing. We're undertaking four investigations to consider how working conditions can be optimised to support patient safety, while maintaining and improving NHS staff wellbeing.
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Launched

  • Theme:

    Patient safety themes, NHS staff
Ambulance crew with patient
HSIB legacy content

Harm caused by delays in transferring patients to the right place of care

published
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.
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Published

  • Theme:

    Emergency care

  • Awaiting safety recommendation responses

Operating theatre
HSIB legacy content

The selection and insertion of vascular grafts in haemodialysis patients

published
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.
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Published

  • Theme:

    Medical devices, Coronavirus (COVID-19), Surgical

  • Safety recommendation responses received

Healthcare professional holds a patient's hand
HSIB legacy content

Variations in the delivery of palliative care services to adults

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

  • Theme:

    Access to care

  • Awaiting safety recommendation responses

A blurred hospital corridor with bright ceiling lights.

Mental health inpatient settings

We’ve started work to launch a series of patient safety investigations that look at mental health inpatient settings. This series of investigations was announced by the Secretary of State for Health and Social Care in June 2023.
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Launched

  • Theme:

    Mental health
A Black patient lies in a hospital bed with their eyes closed.
HSIB legacy content

Invasive procedures in patients with sickle cell disease

published
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.
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Published

  • Theme:

    Long-term conditions, Communication and decision making

  • Safety recommendation responses received

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