Patient safety investigations

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Yellow, blue and red prescription drug capsules.
HSIB legacy content

Potential under-recognised risk of harm from the use of propranolol

published
This patient safety investigation explores the under recognised toxicity of propranolol in overdose. Propranolol is used to treat medical conditions including migraine, cardiovascular problems and the physical effects of anxiety.
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Published

  • Theme:

    Medication, Communication and decision making

  • Safety recommendation responses received

A patient lies in a hospital bed with a monitor on their finger.
HSIB legacy content

Delayed recognition of acute aortic dissection

published
Acute aortic dissection is a relatively rare but life-threatening condition. It requires rapid recognition and urgent treatment in a specialist centre. The symptoms and signs can be confusing and aortic dissection may be mistaken for other conditions, leading to delay in diagnosis.
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Published

  • Theme:

    Emergency care, Communication and decision making

  • Safety recommendation responses received

A patient has an eye examination.
HSIB legacy content

Lack of timely monitoring of patients with glaucoma

published
Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month suffer severe or permanent sight loss as a result of the delays.
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Published

  • Theme:

    Access to care, Follow-up care

  • Safety recommendation responses received

A woman in labour grips her birth partner's hand.
HSIB legacy content

Detection of retained vaginal swabs and tampons following childbirth

published
Retained vaginal swabs are classed as a ‘never event’. A never event is a serious incident that is entirely preventable. Data compiled by NHS England/Improvement shows that accidental retention of vaginal swabs is the most common never event in the ‘retained foreign objects’ category.
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Published

  • Theme:

    Medical devices, Checking

  • Safety recommendation responses received

A healthcare professional taps a tablet computer.
HSIB legacy content

Electronic prescribing and medicines administration systems and safe discharge

published
We’ve identified a significant safety risk posed by poorly implemented electronic prescribing and medicines administration (ePMA) systems. An ePMA system supports the safe, effective, and cost-effective use of medicines from a patient’s admission to hospital until their discharge.
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Published

  • Theme:

    Medication, Access to care

  • Safety recommendation responses received

A male patient lays asleep in a hospital bed.
HSIB legacy content

Management of chronic health conditions in prisons

published
Each day around 120 prisoners with ongoing medication needs are moved between prisons. This investigation identifies opportunities and remedies that could be applied across the system to reduce the risk of prisoners with long term, chronic conditions being moved without crucial medication.
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Published

  • Theme:

    Long-term conditions, Access to care

  • Safety recommendation responses received

Blood samples in tubes with red and blue caps.
HSIB legacy content

Wrong patient details on blood sample

published
Wrong blood in tube (WBIT) incidents can occur when blood samples are taken from patients and are either miscollected (blood is taken from the wrong patient but labelled with the correct patient details) or mislabelled (blood is taken from the intended patient but labelled with the incorrect patien…
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Published

  • Theme:

    Checking, Medical tests

  • Safety recommendation responses received

Two emergency call centre workers sit next to each other wearing headsets.
HSIB legacy content

Management of acute onset testicular pain

published
This investigation looks at delayed diagnosis of testicular torsion. This is a condition where the testicle twists, cuts off the blood supply and results in significant pain. If not treated in time it can result in the loss of a testicle.
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Published

  • Theme:

    Emergency care, Access to care

  • Safety recommendation responses received

Button batteries.
HSIB legacy content

Undetected button/coin cell battery ingestion in children

published
This investigation looks at the undetected ingestion of button/coin cell batteries in children. It follows a reference event where a child died following the unknown and undetected ingestion of a coin cell battery.
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Published

  • Theme:

    Emergency care, Communication and decision making

  • Safety recommendation responses received

X-ray of a shoulder and chest.
HSIB legacy content

Failures in communication or follow-up of unexpected significant radiological findings

published
X-rays are the most common radiological examination. 22.9 million were carried out in the NHS in 2016/17. Failures in communication or follow-up of unexpected significant radiological findings is a nationally recognised patient safety risk. 
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Published

  • Theme:

    Access to care, Medical tests

  • Safety recommendation responses received

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