Patient safety investigations

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Healthcare worker with head in hands

Sexual safety: the implications for patient safety

published
There 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

  • Theme:

    NHS staff, Patient and family
A nurse holds the hands of a patient. You can't see their heads, the focus is on their arms.

Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare

published
Independent 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

  • Theme:

    Patient safety themes
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)

We have launched three investigations to help address patient safety risks associated with sepsis.
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Launched

  • Theme:

    Delayed diagnosis, Hospital care, Patient safety themes
A young girl with an unhappy look on her face lies on her side in a hospital bed, hugging her teddy.

Keeping children and young people with mental health needs safe: the design of the paediatric ward

published
This 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

  • Theme:

    Mental health, Acute, Ward design

  • Awaiting safety recommendation responses

A sad looking woman lies awake on a hospital bed.

Patients at risk of self-harm: continuous observation

published
This 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

  • Theme:

    Hospital care

  • Awaiting safety recommendation responses

Two purple feeding pumps.

Nutrition management of acutely unwell patients in acute medical units

published
Acute 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

  • Theme:

    Acute, Hospital care, Continuity of care
A nurse wearing scrubs prepares surgical instruments including swabs.

Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports

published
Retained 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

  • Theme:

    Medical devices, Checking, Surgical

  • Awaiting safety recommendation responses

A male patient's hand rests on a nurse call button in a hospital bed

Positive patient identification

published
We'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.
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Published

  • Theme:

    Communication and decision making, Checking

  • Safety recommendation responses received

An anaesthetist performs a nasotracheal intubation of a child.

Advanced airway management in patients with a known complex disease

published
This 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.
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Published

  • Theme:

    Acute, Respiratory

  • Safety recommendation responses received

An older male patient talks to a GP, sat either side of a desk in a consulting room.

Continuity of care: delayed diagnosis in GP practices

published
While 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.
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Published

  • Theme:

    Primary care, Delayed diagnosis, Continuity of care

  • Safety recommendation responses received

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