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 that look at medication related harm.
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Published

  • Theme:

    Medication, Communication and decision making, 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 four investigation reports in this series span emergency care response, continuity of care, data sharing and IT, and needs assessments and disability access.
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Published

  • Theme:

    Emergency care, Communication and decision making, Continuity of care

  • Safety recommendation responses received

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

Insulin: supporting safe administration in inpatient settings

published
This investigation examines risks to safety when patients who take insulin are admitted to acute hospitals. Insulin is a high risk medication and remains one of the most common causes of harm from medication errors in the NHS.
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Published

  • Theme:

    Medication, Long-term conditions, Hospital care

  • Safety recommendation responses received

Hands type on a laptop keyboard. Nine exclamation marks are superimposed over the photo, including one in a warning triangle, to signify an issue with the computer system.

Electronic patient record systems – risk from loss of functionality

We have launched an investigation that explores risks to patient safety where access to, the use of, or functionality of electronic patient record (EPR) systems has been lost. That loss may be short- or long-term, and be planned or unplanned.
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Launched

  • Theme:

    Communication and decision making, Medical tests, Continuity of care
A male nurse kneels next to a female patient laying in a bed on a hospital corridor.

Patient care in temporary care environments

published
This investigation explores the management of patient safety risks associated with using temporary care environments, often referred to as ‘corridor care’ and ‘temporary escalation spaces’.
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Published

  • Theme:

    Acute, Emergency care, Patient safety themes
A man in scrubs intently using a tablet computer in a clinical setting.

Electronic patient record (EPR) systems – thematic review

published
This thematic review of 50 HSSIB reports identifies specific patient safety issues and learning related to EPR systems. The report includes a safety observation and local-level learning prompts around safe selection and procurement, implementation and ongoing optimisation of EPR systems.
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Published

  • Theme:

    NHS staff, Communication and decision making, Medical devices
Close-up of man with a closely trimmed beard. He takes a pill with a glass of water.

The use of lithium for bipolar disorder

Around 1 in 50 adults experience bipolar disorder within their lives. Whilst the number of people with bipolar disorder has remained consistent over time the prescribing of lithium has been in decline for decades.
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Launched

  • Theme:

    Mental health, Medication
Collage of enlarged eyes seen through hand held magnifying glasses.

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

published
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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Published

  • Theme:

    NHS staff, Patient safety themes, Patient and family
An image of a hospital waiting room with three empty seats and one seat occupied.

Safety issues for people experiencing a mental health crisis who come into contact with urgent and emergency care services

Mental health crisis describes when a person feels at breaking point and where they need urgent help. We have launched two investigations that explore the patient safety issues associated with care pathways for people experiencing a mental health crisis who come into contact with urgent and emergen…
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Launched

  • Theme:

    Mental health, Emergency care, Access to care

  • Awaiting safety recommendation responses

Image shows a pregnant person holding palms in a heart shape

An exploratory review of maternity and neonatal services

published
This report is a summary of information HSSIB collected during an exploratory review of maternity and neonatal services in spring 2025. This exploratory review involved meetings with 17 stakeholders and a review of 35 safety concerns submitted to HSSIB and one report published in 2021 by the Health…
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Published

  • Theme:

    Maternity investigations, Neonatal
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