Patient safety investigations

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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)

  • Awaiting safety recommendation responses

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

Entrance to a hospital Emergency Department.
HSIB legacy content

Non-accidental injuries in infants attending the emergency department

published
This investigation explores the challenges for clinicians associated with making the clinical judgement as to whether an injury is accidental or not. Please note that due to the subject matter of this report it contains details which some readers may find distressing.
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Published

  • Theme:

    Missed diagnosis

  • Safety recommendation responses received

A central venous catheter (CVC) machine used for haemodialysis in kidney patients.
HSIB legacy content

Safety risk of air embolus associated with central venous catheters used for haemodialysis treatment

published
This investigation aims to improve patient safety by supporting healthcare staff in the safe use of central venous catheters to access a patient’s blood supply.
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Published

  • Theme:

    Medical devices

  • Safety recommendation responses received

Illustration of a lit up brain hovering over an outstretched palm.
HSIB legacy content

Care delivery within community mental health teams

published
In 2018, there were 1,306 suicides in England by people who had been in contact with mental health services in the previous 12 months. This investigation emphasises that NHS trusts should move away from standardised scoring tools that categorise a patient as high, medium or low risk, as they are a …
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Published

  • Theme:

    Mental health

  • Safety recommendation responses received

A pregnant woman lays back, cradling her bump.
HSIB legacy content

Assessment of risk during the maternity pathway

published
Despite a wealth of national guidance, risk assessments in the maternity pathway remain a significant challenge. This national learning report highlights the need for a personalised and dynamic risk assessment approach.
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Published

  • Theme:

    Maternity
A sad looking woman lies awake on a hospital bed.

The clinical observation of patients detained under the Mental Health Act at risk of self-harm in acute hospitals

This investigation explores the barriers and enablers to the clinical observation of adults at risk of self-harm who are detained under the Mental Health Act in an acute hospital.
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Launched

  • Theme:

    Hospital care
A healthcare professional looks at notes at the hospital bedside of a patient lying on a bed behind them.
HSIB legacy content

Access to critical patient information at the bedside

published
This investigation explores the challenges NHS hospital staff face when trying to access key information about their patients, at the patient bedside.
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Published

  • Theme:

    Cardiac, Communication and decision making

  • Safety recommendation responses received

A newborn baby with yellowing of the whites of their eyes caused by jaundice.
HSIB legacy content

Detection of jaundice in newborn babies

published
Jaundice is a common condition in newborn babies, with 1 in 20 requiring treatment. This national investigation explores safety issues associated with delayed diagnosis of jaundice in newborn babies.
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Published

  • Theme:

    Neonatal, Missed diagnosis

  • Awaiting safety recommendation responses

A woman rests her head on the edge of a birth pool during labour.

Factors affecting the delivery of safe care in midwifery units

This national learning report analyses a sample of 93 investigations completed by the maternity programme formerly and presents the key themes.
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Launched

  • Theme:

    Patient safety themes, Access to care, Maternity
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