Patient safety investigations

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A nurse helps an older male patient to stand up from his hospital bed.

Caring for adults with a learning disability in acute hospitals

published
This 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.
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Published

  • Theme:

    Hospital care, Learning disabilities

  • Safety recommendation responses received

A space shuttle launches into a blue sky.

Safety management systems: an introduction for healthcare

published
Safety management systems are an organised approach to managing safety which are widely used in different industries. This national learning report looks at what could be achieved by further adopting this approach in healthcare.
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Published

  • Theme:

    NHS staff, Patient safety themes, Patient and family

  • Safety recommendation responses received

A district nurse cares for an elderly man with a head injury in his living room at home.

Workforce and patient safety

The workforce challenges faced by the NHS in England present a significant risk to patient safety and staff wellbeing. We're undertaking three investigations to consider how working conditions can be optimised to support patient safety, while maintaining and improving NHS staff wellbeing.
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Launched

  • Theme:

    NHS staff, Patient safety themes

  • Awaiting safety recommendation responses

Ambulance crew with patient
HSIB legacy content

Harm caused by delays in transferring patients to the right place of care

published
This investigation explores issues around patient handover to emergency care. Patients who wait in ambulances at an emergency department are at potential risk of coming to harm due to deterioration or not being able to access timely and appropriate treatment.
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Published

  • Theme:

    Emergency care

  • Awaiting safety recommendation responses

Operating theatre
HSIB legacy content

The selection and insertion of vascular grafts in haemodialysis patients

published
Almost 30,000 people in the UK currently receive dialysis. This investigation looks at associated patient safety risks in operating theatres, and packaging of vascular grafts.
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Published

  • Theme:

    Medical devices, Surgical, Coronavirus (COVID-19)

  • Safety recommendation responses received

Healthcare professional holds a patient's hand
HSIB legacy content

Variations in the delivery of palliative care services to adults

published
This national investigation looks at variations in delivery of palliative care services to adults in England, by the NHS, charities and private sector.
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Published

  • Theme:

    Access to care

  • Awaiting safety recommendation responses

A blurred hospital corridor with bright ceiling lights.

Mental health inpatient settings

We’ve started work to launch a series of patient safety investigations that look at mental health inpatient settings. This series of investigations was announced by the Secretary of State for Health and Social Care in June 2023.
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Launched

  • Theme:

    Mental health
A Black patient lies in a hospital bed with their eyes closed.
HSIB legacy content

Invasive procedures in patients with sickle cell disease

published
This investigation looks at the risks for patients with sickle cell disease when they undergo invasive procedures in hospital. It explores how hospital specialities can ensure that patients with sickle cell disease are prepared for procedures which could put them at risk of a sickle cell crisis.
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Published

  • Theme:

    Long-term conditions, Communication and decision making

  • Safety recommendation responses received

A woman laying in a hospital bed talks to a male nurse wearing a face mask and blue scrubs.
HSIB legacy content

Management of sickle cell crisis

published
Sickle cell disease is the name for a group of inherited health conditions that affect the red blood cells. It affects approximately 15,000 people in the UK. This investigation looks at the risks for patients with sickle cell disease when they are treated with morphine for a sickle cell crisis.
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Published

  • Theme:

    Long-term conditions, Medical devices, Coronavirus (COVID-19)

  • Safety recommendation responses received

A clinician wearing a surgical mask types on a laptop on a hospital ward.
HSIB legacy content

Clinical investigation booking systems failures: written communications in community languages

published
This investigation looks at the safety risk of booking systems failures. We explore the use of paper and hybrid booking systems and the production of appointment letters.
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Published

  • Theme:

    Communication and decision making

  • Safety recommendation responses received

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