Get updates via RSS feed

Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
We have launched three investigations to help address patient safety risks associated with sepsis.
Read the summary
Launched
-
Theme:
Delayed diagnosis, Hospital care, 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.
Read the summary
Published
-
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.
Read the summary
Published
-
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.
Read the summary
Published
-
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.
Read the summary
Published
-
Theme:
Medical devices, Checking, Surgical -
Awaiting safety recommendation responses

Positive patient identification
publishedWe've undertaken several investigations where misidentification of patients has been an important part of a patient safety event. This national learning report collates findings and identifies how these misidentifications have been able to happen.
Read the summary
Published
-
Theme:
Communication and decision making, Checking -
Safety recommendation responses received

Advanced airway management in patients with a known complex disease
publishedThis investigation explores intubation of patients with difficult airways. There are no standards for how an anticipated difficult airway is managed. Failure to provide an adequate airway can result in brain injury or death.
Read the summary
Published
-
Theme:
Acute, Respiratory -
Safety recommendation responses received

Continuity of care: delayed diagnosis in GP practices
publishedWhile some GP practices in England operate a formalised system of continuity of care, many do not. This investigation explores the safety risk associated with the lack of a system of continuity of care within GP practices.
Read the summary
Published
-
Theme:
Primary care, Delayed diagnosis, Continuity of care -
Safety recommendation responses received

Risks to medication delivery using ambulatory infusion pumps: design and usability in inpatient settings
publishedAmbulatory infusion pumps are small, battery powered medical devices. This investigation aims to improve patient safety by supporting healthcare staff in the safe use of ambulatory (portable) infusion pumps.
Read the summary
Published
-
Theme:
Medical devices -
Safety recommendation responses received

Caring for adults with a learning disability in acute hospitals
publishedThis investigation explores the care that people with learning disabilities receive in NHS hospitals. It specifically looks at the provision of healthcare to adults with learning disabilities within acute hospital settings.
Read the summary
Published
-
Theme:
Hospital care, Learning disabilities -
Safety recommendation responses received