Patient safety investigations

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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…
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Published

  • Theme:

    Medication, Communication and decision making

  • Safety recommendation responses received

An investigator sits with two family members filling in a form.
HSIB legacy content

Giving families a voice: HSIB’s approach to patient and family engagement during investigations

published
This national learning report highlights the themes emerging from our contact with families during our patient safety investigations. Our national learning reports describe common themes and findings that come out of our national investigation programme and our maternity investigation programme.
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Published

  • Theme:

    Patient and family
Healthcare worker wearing personal protective equipment (PPE).
HSIB legacy content

Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response

published
This national intelligence report provides insight into a safety risk related to PPE requirements for care workers delivering homecare during the COVID-19 response.
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Published

  • Theme:

    Coronavirus (COVID-19)
A mother holds her sleeping newborn baby.
HSIB legacy content

Neonatal collapse alongside skin-to-skin contact

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.
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Published

  • Theme:

    Maternity, Communication and decision making
Healthcare professional in scrubs.
HSIB legacy content

Early warning scores to detect deterioration in COVID-19 inpatients

published
This national intelligence report provides insight into a safety risk when using early warning scores to detect deterioration in patients with coronavirus (COVID-19) on general hospital wards.
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Published

  • Theme:

    Hospital care, Coronavirus (COVID-19)
Lab test.
HSIB legacy content

Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection

published
In February 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. These initial investigations were carried out between April 2018 and December 2019. One of the themes highlighted w…
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Published

  • Theme:

    Maternity, Communication and decision making
A radiographer's hand operates an ultrasound scanner.
HSIB legacy content

Summary of themes arising from the HSIB maternity programme

published
This national learning report highlights the themes emerging from the initial investigations carried out as part of our maternity investigation programme. It looks at maternity investigations carried out by HSIB between April 2018 and December 2019.
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Published

  • Theme:

    Maternity, Patient safety themes
A radiographer prepares a patient for an MRI scan.
HSIB legacy content

Undiagnosed cardiomyopathy in a young person with autism

published
People with additional needs receiving care in hospital may require adjustments to promote their safety and improve their experience of care. This investigation seeks to understand the safety risks associated with patients with additional needs.
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Published

  • Theme:

    Long-term conditions, Communication and decision making

  • Safety recommendation responses received

Ultrasound scanning equipment.
HSIB legacy content

The diagnosis of ectopic pregnancy

published
An estimated 12,000 women experience an ectopic pregnancy each year in the UK. Ectopic pregnancy occurs when the fertilised egg implants outside the uterus, usually in the Fallopian tube. If it’s left untreated, it can rupture and cause internal bleeding.
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Published

  • Theme:

    Emergency care, Communication and decision making

  • Safety recommendation responses received

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