Patient safety investigations

Start date:

Report publication date:

Clear All
Get updates via RSS feed
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.
Read the summary
Published

  • Theme:

    Primary care, Delayed diagnosis, Continuity of care

  • Safety recommendation responses received

A nurse speaks to a cancer patient.

Risks to medication delivery using ambulatory infusion pumps: design and usability in inpatient settings

published
Ambulatory 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

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.
Read the summary
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.
Read the summary
Published

  • Theme:

    NHS staff, Patient safety themes, Patient and family

  • Safety recommendation responses received

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.
Read the summary
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.
Read the summary
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.
Read the summary
Published

  • Theme:

    Access to care

  • Safety recommendation responses received

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.
Read the summary
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.
Read the summary
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.
Read the summary
Published

  • Theme:

    Communication and decision making

  • Safety recommendation responses received

« First Previous
Page 3 of 11
Next Last »