Patient safety investigations

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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 completed three local investigations, and a national investigation is underway, looking at medication related harm.
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Published

  • Theme:

    Medication, Communication and decision making, Continuity of care
Close up of hands using a smart phone.

Online prescribing: challenges and opportunities to improve patient safety

This investigation looks at the complex regulatory landscape around independent online prescribing and challenges sharing patient information between the NHS and independent online prescribing services.
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Launched

  • Theme:

    Medication
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. These investigations 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

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 healthcare assistant wearing blue scrubs checks the blood sugar level of a male patient.

Insulin: supporting safe administration 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 young woman with a pained expression lies in an ambulance with her eyes closed while two paramedics treat her.

12-lead electrocardiograms (ECGs) 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 smiling health visitor wearing green scrubs helps an older woman to walk in her home.

Safety management

published
This investigation considers how safety management is coordinated and integrated across the healthcare system. It looks at accountability beyond organisational boundaries and involving NHS staff and patients.
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Published

  • Theme:

    NHS staff, Patient safety themes, Patient and family, Continuity of care

  • Awaiting safety recommendation responses

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. Second report of four now published.
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Published

  • Theme:

    Emergency care, Communication and decision making, Continuity of care

  • Awaiting safety recommendation responses

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