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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
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
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
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
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
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
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
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Theme:
Maternity
Keeping children and young people with mental health needs safe: the design of the paediatric ward
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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Launched
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Theme:
Mental health, Acute, Ward design
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
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Theme:
Analysis, Emergency care
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