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Patient care in temporary care environments
publishedThis investigation explores the management of patient safety risks associated with using temporary care environments, often referred to as ‘corridor care’ and ‘temporary escalation spaces’.
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Published
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Theme:
Acute, Emergency care, Patient safety themes
Electronic patient record (EPR) systems – thematic review
publishedThis thematic review of 50 HSSIB reports identifies specific patient safety issues and learning related to EPR systems. The report includes a safety observation and local-level learning prompts around safe selection and procurement, implementation and ongoing optimisation of EPR systems.
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Published
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Theme:
NHS staff, Communication and decision making, Medical devices
The use of lithium for bipolar disorder
Around 1 in 50 adults experience bipolar disorder within their lives. Whilst the number of people with bipolar disorder has remained consistent over time the prescribing of lithium has been in decline for decades.
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Launched
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Theme:
Mental health, Medication
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
publishedWe are working on a report to share learning gained from our investigation activities and education programme about patient safety incident investigations under the Patient Safety Incident Response Framework (PSIRF).
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Published
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Theme:
NHS staff, Patient safety themes, Patient and family
An exploratory review of maternity and neonatal services
publishedThis report is a summary of information HSSIB collected during an exploratory review of maternity and neonatal services in spring 2025. This exploratory review involved meetings with 17 stakeholders and a review of 35 safety concerns submitted to HSSIB and one report published in 2021 by the Health…
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Published
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Theme:
Maternity investigations, Neonatal
Workforce and patient safety
publishedThe workforce challenges faced by the NHS in England present a significant risk to patient safety and staff wellbeing. These investigations consider how working conditions can be optimised to support patient safety, while maintaining and improving NHS staff wellbeing.
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Published
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Theme:
NHS staff, Patient safety themes -
Awaiting safety recommendation responses
Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
publishedThree reports that model investigation of sepsis under the Patient Safety Incident Response Framework (PSIRF), to boost local learning and help improve investigation quality in the NHS.
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Published
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Theme:
Delayed diagnosis, Hospital care, Patient safety themes
Mental health inpatient settings
publishedThis series of patient safety investigations look at mental health inpatient settings. They were directed by the Secretary of State for Health and Social Care. We've completed five investigations and an overarching report that explores cross-cutting patient safety risks.
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Published
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Theme:
Mental health -
Safety recommendation responses received
The impact of staff fatigue on patient safety
publishedStaff fatigue contributes directly and indirectly to patient harm. Yet fatigue is not routinely considered in patient safety event reporting or learning reviews. We share safety recommendations and learning for healthcare organisations to increase their understanding of staff fatigue. This includes…
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Published
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Theme:
NHS staff, Patient safety themes -
Safety recommendation responses received
12-lead electrocardiograms (ECGs) in ambulance services
publishedThese two investigations will help to address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST Elevated Myocardial Infarction (StEMI).
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Published
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Theme:
Emergency care, Cardiac -
Safety recommendation responses received