Patient safety investigations

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A nurse wearing scrubs prepares surgical instruments including swabs.

Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports

published
Retained swabs are classed as Never Events. Data shows there has been 11-23 retained swab incidents per year since 2015. The investigation was launched after we examined the case of a patient who had two swabs left in her chest following serious heart surgery.
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Published

  • Theme:

    Medical devices, Checking, Surgical

  • Awaiting safety recommendation responses

A male patient's hand rests on a nurse call button in a hospital bed

Positive patient identification

published
We've undertaken several investigations where misidentification of patients has been an important part of a patient safety event. This national learning report collates findings and identifies how these misidentifications have been able to happen.
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Published

  • Theme:

    Communication and decision making, Checking

  • Safety recommendation responses received

An anaesthetist performs a nasotracheal intubation of a child.

Advanced airway management in patients with a known complex disease

published
This investigation explores intubation of patients with difficult airways. There are no standards for how an anticipated difficult airway is managed. Failure to provide an adequate airway can result in brain injury or death.
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Published

  • Theme:

    Acute, Respiratory

  • Safety recommendation responses received

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.
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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.
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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.
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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.
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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.
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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.
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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.
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Published

  • Theme:

    Access to care

  • Safety recommendation responses received

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