Patient safety investigations

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A dentist looks at X-rays of teeth.
HSIB legacy content

Wrong site surgery – wrong tooth extraction

published
Wrong tooth extraction is the most common form of wrong site surgery reported over the past five years. This is classed as a Never Event - patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at …
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Published

  • Theme:

    Checking, Surgical

  • Safety recommendation responses received

Blurred hospital corridor with staff member walking.
HSIB legacy content

Provision of mental health care to patients presenting at the emergency department

published
In England, it is estimated that 5% of all hospital emergency department attendances are primarily due to mental ill-health. This investigation reinforces the need for emergency mental health care 24 hours a day, seven days a week.
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Published

  • Theme:

    Mental health, Access to care

  • Safety recommendation responses received

A blurred ambulance travels at speed past the Houses of Parliament in London.
HSIB legacy content

Emergency response to heart attack

published
This investigation looks at the emergency response to heart attack across the NHS in England.
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Published

  • Theme:

    Emergency care, Access to care

  • Safety recommendation responses received

A patient's hand rests on their hospital bed with an unused cannula in place.
HSIB legacy content

Residual drugs in intravenous cannulae and extension lines

published
This patient safety investigation looks at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines.
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Published

  • Theme:

    Medical devices, Checking

  • Safety recommendation responses received

A tired healthcare worker wearing personal protective equipment (PPE) sits with their head in their hands.
HSIB legacy content

Learning from maternal death investigations during the first wave of the COVID-19 pandemic

published
We have carried out a themed review of our maternal death investigations during the coronavirus (COVID-19) pandemic.
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Published

  • Theme:

    Maternity, Coronavirus (COVID-19)
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.
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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

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