Patient safety investigations

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A mother cradles a newborn baby.
HSIB legacy content

Severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia

published
In March 2020, we published a national learning report to highlight the themes emerging from the initial investigations carried out as part of our maternity investigation programme.
Read the summary
Published

  • Theme:

    Maternity, Communication and decision making

  • Safety recommendation responses received

Blurred hospital staff in a corridor.
HSIB legacy content

Never events: analysis of HSIB's national investigations

published
This national learning report analyses the findings of the investigations previously carried out by HSIB concerning incidents classified as never events.
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Published

  • Theme:

    Never events

  • Safety recommendation responses received

Two people wearing masks sit distanced on a sofa, talking.
HSIB legacy content

Support for staff following patient safety incidents

published
This national learning report explores HSIB’s insights into how NHS staff are supported by their trusts following patient safety incidents, with a focus on good practice.
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Published

  • Theme:

    NHS staff
A blurred hospital corridor with a healthcare professional walking away and a drip stand in the foreground.
HSIB legacy content

Placement of nasogastric tubes

published
This investigation looks at nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice.
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Published

  • Theme:

    Medical devices, Checking

  • Safety recommendation responses received

A smart infusion pump at a patient's bedside.
HSIB legacy content

Procurement, usability and adoption of ‘smart’ infusion pumps

published
Although the aim of smart infusion pumps is to improve patient safety, the technology can introduce new risks. This investigation focused on understanding the challenges involved in introducing smart infusion pump technology within NHS hospitals.
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Published

  • Theme:

    Communication and decision making, Medical devices

  • Safety recommendation responses received

A woman lies on a hospital bed in labour.
HSIB legacy content

Delays to intrapartum intervention once fetal compromise is suspected

published
We have identified a safety risk in maternity care relating to delays to intrapartum intervention once fetal compromise is suspected. The term intrapartum refers to the period of time spanning the commencement of labour, the birth of the baby and the delivery of the placenta and membranes.
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Published

  • Theme:

    Maternity, Communication and decision making

  • Safety recommendation responses received

A hospital worker walks along a corridor.
HSIB legacy content

Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation

published
This prospective patient safety investigation looks at how hospitals can minimise the likelihood of patients catching coronavirus (COVID-19) on acute hospital wards.
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Published

  • Theme:

    Hospital care, Coronavirus (COVID-19)

  • Safety recommendation responses received

Empty hospital bed in a corridor.
HSIB legacy content

Unplanned delayed removal of ureteric stents

published
This investigation relates to patients with kidney stones who have had a ureteric stent inserted and where the stent is left in longer than planned.
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Published

  • Theme:

    Access to care, Follow-up care

  • Safety recommendation responses received

Blurred healthcare professionals rushing past empty beds on a hospital corridor.
HSIB legacy content

Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke

published
Every year in the UK over 100,000 people have a stroke. Patients who are admitted to hospital for any reason, including stroke, are assessed for their risk of developing blood clots in their veins which may arise due to being less active than usual.
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Published

  • Theme:

    Acute

  • Safety recommendation responses received

An unseen patient rests their hand on a hospital bed, with an unused cannula inserted on the top of their hand.
HSIB legacy content

The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital

published
Research suggests that 237 million medication errors occur at some point in the medication process in England per year. When errors occur in prescribing high-risk medications for older patients with multiple medical problems, there is a significant risk of serious harm. High-risk medicines are thos…
Read the summary
Published

  • Theme:

    Medication, Communication and decision making

  • Safety recommendation responses received

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