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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 -
Awaiting safety recommendation responses
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 -
Awaiting safety recommendation responses
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 -
Awaiting safety recommendation responses
Safety management
publishedThis investigation considers how safety management is coordinated and integrated across the healthcare system. It looks at accountability beyond organisational boundaries and involving NHS staff and patients.
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Published
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Theme:
NHS staff, Patient safety themes, Patient and family, Continuity of care -
Awaiting safety recommendation responses
Sexual safety: the implications for patient safety
publishedThere is evidence of widespread sexism, sexual misconduct and harassment in healthcare. Between May and September 2024, we carried out exploratory work to consider the potential of conducting an investigation into patient safety risks associated with sexual safety.
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Published
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Theme:
NHS staff, Patient and family
Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare
publishedIndependent report published by the Health Services Safety Investigations Body and arm's-length body members of the Recommendations to Impact Collaborative Group.
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Published
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Theme:
Patient safety themes
Keeping children and young people with mental health needs safe: the design of the paediatric ward
publishedThis 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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Published
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Theme:
Mental health, Acute, Ward design -
Awaiting safety recommendation responses
Patients at risk of self-harm: continuous observation
publishedThis investigation has found limited evidence that the current approach to continuous observation of adult patients at risk of self-harm on hospital wards is effective.
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Published
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Theme:
Hospital care -
Awaiting safety recommendation responses