Patient safety investigations

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A mother holds the feet of premature twin babies.
HSIB legacy content

Management of preterm labour and birth of twins

published
Preterm birth is one of the main causes for under-five mortality (death) and disability worldwide. 60% of twin pregnancies result in premature birth. This investigation considers the existing knowledge and management of preterm labour and birth of twins.
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Published

  • Theme:

    Maternity
A nurse presses a button on a patient monitor in a critical care unit.
HSIB legacy content

The use of an appropriate flush fluid with arterial lines

published
This investigation aims to understand the risks for patients associated with blood sampling from arterial line systems used in adult critical care.
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Published

  • Theme:

    Medication, Medical devices, Checking

  • Safety recommendation responses received

A healthcare professional fills a syringe with medication.
HSIB legacy content

Administering high-strength insulin from a pen device in hospital

published
This patient safety investigation looks at administering insulin from a pen device in hospitals. In 2017 there were 260,000 people with diabetes in the UK who experienced a medication error.
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Published

  • Theme:

    Medication, Checking
Blue capsules spill out of a foil packet.
HSIB legacy content

Medicine omissions in learning disability secure units

published
This investigation looks at patients on learning disability secure units who do not receive medicines that have been prescribed to them.
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Published

  • Theme:

    Medication, Access to care

  • Safety recommendation responses received

A member of hospital staff from the sterile services department cleans surgical instruments, wearing scrubs, hair net, gloves and a mask.
HSIB legacy content

Decontamination of surgical instruments

published
Detailed examination of how the risk of contamination is currently managed within NHS trusts. Our investigation identifies regulatory and assurance gaps, plus four safety recommendations to address them.
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Published

  • Theme:

    Hospital care, Surgical

  • Safety recommendation responses received

An older man lies on a bed with his worried wife sitting with him, holding his hand.
HSIB legacy content

Unintentional overdose of morphine sulfate oral solution

published
In this investigation we share Len's story. He took an accidental overdose of morphine sulfate oral liquid while at home. We've made two safety observations, relevant to manufacturers of morphine liquids, and to encourage participation in HSIB investigations.
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Published

  • Theme:

    Medication
Two young people wearing rainbow bracelets hold hands outside in the sunshine.
HSIB legacy content

Provision of care for children and young people when accessing specialist gender dysphoria services

published
This investigation explores the care of patients who present to child and adolescent mental health services (CAMHS) with questions about their gender identity and are referred to specialist gender dysphoria services.
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Published

  • Theme:

    Access to care

  • Safety recommendation responses received

A London ambulance pulls up outside the Emergency Department at a hospital.
HSIB legacy content

Clinical decision making: diagnosis of pulmonary embolism in emergency departments

published
A person suffering from a pulmonary embolism (PE) requires urgent treatment to reduce the chance of significant harm or death. Any delay in recognising the symptoms of PE and treatment of the suspicion of PE increases risk that a patient may suffer harm.
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Published

  • Theme:

    Communication and decision making, Hospital care

  • Safety recommendation responses received

The exterior front entrance of a hospital emergency department, with ambulances parked outside.
HSIB legacy content

Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to emergency care

published
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.
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Published

  • Theme:

    Emergency care
A sleeping newborn baby with brown hair wears an oxygen mask, with a plaster holding a tube in place on their face.
HSIB legacy content

Emergency neonatal blood transfusion at birth following acute blood loss during labour and/or delivery

published
This investigation looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. Delays in neonatal blood transfusion emerged as a safety risk from investigations carried out under our maternity investigation programme.
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Published

  • Theme:

    Maternity, Neonatal

  • Safety recommendation responses received

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