Patient safety investigations

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Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development

We are working on a report to share learning gained from our investigation activities and education programme about patient safety incident investigations under the Patient Safety Incident Response Framework (PSIRF).
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Launched

  • Theme:

    NHS staff, Patient safety themes, Patient and family
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.

Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)

published
Three reports that model investigation of sepsis under the Patient Safety Incident Response Framework (PSIRF), to boost local learning and help improve investigation quality in the NHS.
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Published

  • Theme:

    Delayed diagnosis, Hospital care, Patient safety themes
A young diabetic woman holds a syringe pen to inject insulin.

Insulin: supporting safe self-administration in vulnerable patient groups in the community

We have launched an investigation that explores risks to patient safety for patients in the community who self-administer insulin and who may be at increased risk of harm because of their circumstances.
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Launched

  • Theme:

    Mental health, Medication, Learning disabilities
A healthcare assistant wearing blue scrubs checks the blood sugar level of a male patient.

Insulin: administration of insulin at the right dose and right time in inpatient settings

We have launched an investigation to examine risks to patient safety when patients who take insulin are admitted to acute hospitals.
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Launched

  • Theme:

    Medication, Long-term conditions, Hospital care
A blurred hospital corridor with bright ceiling lights.

Mental health inpatient settings

published
This series of patient safety investigations look at mental health inpatient settings. They were directed by the Secretary of State for Health and Social Care. We've completed five investigations and an overarching report that explores cross-cutting patient safety risks.
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Published

  • Theme:

    Mental health

  • Awaiting safety recommendation responses

A young burnt out doctor sits resting his chin on his hands.

The impact of staff fatigue on patient safety

published
Staff fatigue contributes directly and indirectly to patient harm. Yet fatigue is not routinely considered in patient safety event reporting or learning reviews. We share safety recommendations and learning for healthcare organisations to increase their understanding of staff fatigue. This includes…
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Published

  • Theme:

    NHS staff, Patient safety themes

  • 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

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

  • Theme:

    NHS staff, Patient safety themes

  • Awaiting safety recommendation responses

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

published
These two investigations will help to address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST Elevated Myocardial Infarction (StEMI).
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Published

  • Theme:

    Emergency care, Cardiac

  • Awaiting safety recommendation responses

A female nurse gives an older woman medical pills.

Medication related harm

published
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. Two reports have been published so fa…
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Published

  • Theme:

    Medication, Communication and decision making, Continuity of care
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Electronic patient record (EPR) systems – thematic review

We have launched a thematic review of HSSIB’s work to date to identify specific patient safety issues and learning related to electronic patient record (EPR) systems.
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Launched

  • Theme:

    NHS staff, Communication and decision making, Medical devices
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