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Pre-hospital interpretation of electrocardiograms (ECG) in ambulance services
publishedThese 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
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Theme:
Emergency care, Cardiac -
Awaiting safety recommendation responses

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
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Theme:
NHS staff, Communication and decision making, Medical devices

Safety management
publishedThis 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
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Theme:
NHS staff, Patient safety themes, Patient and family, Continuity of care -
Awaiting safety recommendation responses

Healthcare provision in prisons
publishedWe'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
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Theme:
Emergency care, Communication and decision making, Continuity of care -
Awaiting safety recommendation responses

Sexual safety: the implications for patient safety
publishedThere is evidence of widespread sexism, sexual misconduct and harassment in healthcare. Between May and September 2024, we carried out exploratory work to consider the potential of conducting an investigation into patient safety risks associated with sexual safety.
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Published
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Theme:
NHS staff, Patient and family

Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare
publishedIndependent 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
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Theme:
Patient safety themes

Keeping children and young people with mental health needs safe: the design of the paediatric ward
publishedThis 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
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Theme:
Mental health, Acute, Ward design -
Awaiting safety recommendation responses

Patients at risk of self-harm: continuous observation
publishedThis 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
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Theme:
Hospital care -
Awaiting safety recommendation responses

Nutrition management of acutely unwell patients in acute medical units
publishedAcute 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
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Theme:
Acute, Hospital care, Continuity of care

Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports
publishedRetained 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
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Theme:
Medical devices, Checking, Surgical -
Awaiting safety recommendation responses