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HSIB legacy content
Recognising and responding to critically unwell patients
published
Problems in recognising and responding to deteriorating patients continues to be a major source of severe harm and preventable death in hospitals. Previous research has shown that up to a quarter of preventable deaths are related to failures in clinical monitoring.
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Published
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Theme:
Communication and decision making, Hospital care -
Safety recommendation responses received
HSIB legacy content
Inadvertent administration of an oral liquid into a vein
published
This investigation emphasises that complex and fragmented medicine safety processes are putting patients across the country at risk. The report puts forward safety recommendations aimed at driving national improvement to reduce potentially fatal medication errors.
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Published
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Theme:
Medication, Checking -
Safety recommendation responses received
HSIB legacy content
Piped supply of medical air and oxygen
published
This investigation focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.
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Published
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Theme:
Never events -
Safety recommendation responses received
HSIB legacy content
Transfer of critically ill adults
published
This investigation looks at the transfer of critically ill adults. It has previously been referred to as 'Cardiac and vascular pathways', but the original investigation was split. This is part one of the investigation.
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Published
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Theme:
Access to care, Hospital care -
Safety recommendation responses received
HSIB legacy content
Design and safe use of portable oxygen systems
published
NHS Improvement issued a patient safety alert on medical devices in January 2018. It highlighted 400 incidents - including six deaths - over three years that involved the incorrect operation of oxygen cylinder controls. This investigation reinforces that alert and makes further safety recommendatio…
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Published
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Theme:
Medical devices, Checking -
Safety recommendation responses received
HSIB legacy content
Insertion of an incorrect intraocular lens
published
Cataract removal and implantation of an artificial lens is the most common surgical procedure undertaken by the NHS. Insertion of an incorrect intraocular lens was the most commonly reported never event in England between April 2016 and March 2017. A never event is a serious incident that is entire…
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Published
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Theme:
Checking, Surgical -
Safety recommendation responses received
HSIB legacy content
Administering a wrong site nerve block
published
This investigation seeks to identify opportunities and systemic remedies to reduce the risk of wrong site anaesthetic nerve blocks occurring. Anaesthetic nerve blocks are injections to block pain in a specific region of the body.
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Published
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Theme:
Checking, Surgical -
Safety recommendation responses received
HSIB legacy content
Implantation of wrong prostheses during joint replacement surgery
published
This investigation relates to the implantation of the wrong prostheses (artificial body parts) during joint replacement surgery - a surgical never event. A never event is a serious incident that is entirely preventable.
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Published
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Theme:
Checking, Surgical -
Safety recommendation responses received
HSIB legacy content
Transition from child and adolescent mental health services to adult mental health services
published
We investigate how young people are supported in the transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) when they turn 18 years old.
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Published
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Theme:
Mental health, Access to care -
Safety recommendation responses received