Patient safety investigations

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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 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:

    Communication and decision making, Cardiac
  • 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:

    Missed diagnosis, Neonatal
  • Safety recommendation responses received

A heavily pregnant woman sits down to fill in a form.
HSIB legacy content

The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period

published
Venous thromboembolism is the collective term for the formation of blood clots, including deep vein thrombosis and pulmonary embolism. Pregnant women could suffer a potentially fatal blood vessel blockage if their risk is not properly assessed during pregnancy and the first six weeks after birth.
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Published
  • Theme:

    Maternity
Two healthcare workers have a conversation whilst walking along a hospital corridor.
HSIB legacy content

HSIB’s local investigation pilot: shared learning for local healthcare systems

published
Our local investigation pilot was launched to evaluate our ability to carry out effective locality-based patient safety investigations with actions aimed at specific NHS organisations, while still identifying and sharing relevant national learning.
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Published
  • Theme:

    Analysis, Emergency care
An NHS 111 call handler speaks into a headset.
HSIB legacy content

NHS 111’s response to callers with Covid-19-related symptoms during the pandemic

published
The purpose of this investigation is to support improvements in the delivery of NHS 111 and other telephone triage services during a national healthcare emergency.
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Published
  • Theme:

    Emergency care, Coronavirus (COVID-19)
  • Safety recommendation responses received

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