HSIB investigations

Articles in this category

1. National learning report: Never Events analysis of HSIB's national investigations report (21 January 2021)

   • Never event
   • Recommendations
   • (and 2 more)

     Tagged with:

     • Never event
     • Recommendations
     • Investigation
     • Patient safety incident

   By PatientSafetyLearning Team, Thursday at 11:37

   • 0 comments
   • 195 views
   • 
   • Added by PatientSafetyLearning Team
   • Thursday at 11:37

2. HSIB: Placement of nasogastric tubes (December 2020)

   • Investigation
   • Recommendations
   • (and 2 more)

     Tagged with:

     • Investigation
     • Recommendations
     • Never event
     • Adminstering medication

   By Patient Safety Learning, 17 December, 2020

   • 0 comments
   • 211 views
   • 
   • Added by Patient Safety Learning
   • 17 December, 2020

3. HSIB: Investigation into the procurement, usability and adoption of ‘smart’ infusion pumps (3 December 2020)

   • Investigation
   • Adminstering medication
   • (and 5 more)

     Tagged with:

     • Investigation
     • Adminstering medication
     • Medical device
     • Recommendations
     • Patient safety incident
     • Implementation
     • Technology

   By Patient Safety Learning, 3 December, 2020

   • 0 comments
   • 201 views
   • 
   • Added by Patient Safety Learning
   • 3 December, 2020

4. HSIB: Delays to intrapartum intervention once fetal compromise is suspected (November 2020)

   • Investigation
   • Maternity
   • (and 10 more)

     Tagged with:

     • Investigation
     • Maternity
     • Baby
     • Labour
     • Monitoring
     • Psychological safety
     • Recommendations
     • Patient death
     • Patient harmed
     • Lack of resources
     • Safe staffing
     • Organisation / service factors

   By Patient Safety Learning, 12 November, 2020

   • 0 comments
   • 194 views
   • 
   • Added by Patient Safety Learning
   • 12 November, 2020

5. HSIB: Investigation into management of venous thromboembolism risk in patients following thrombolysis for an acute stroke (October 2020)

   • Investigation
   • Deep vein thrombosis
   • (and 1 more)

     Tagged with:

     • Investigation
     • Deep vein thrombosis
     • Stroke

   By PatientSafetyLearning Team, 9 November, 2020

   • 0 comments
   • 38 views
   • 
   • Added by PatientSafetyLearning Team
   • 9 November, 2020

6. HSIB: COVID-19 transmission in hospitals: management of the risk – a prospective safety investigation (October 2020)

   • Virus
   • Pandemic
   • (and 5 more)

     Tagged with:

     • Virus
     • Pandemic
     • Infection control
     • Investigation
     • Interview
     • Data
     • Organisation / service factors

   By Patient Safety Learning, 29 October, 2020

   • 0 comments
   • 210 views
   • 
   • Added by Patient Safety Learning
   • 29 October, 2020

7. HSIB: Summary report. Unplanned delayed removal of ureteric stents (October 2020)

   • Investigation
   • Recommendations
   • (and 1 more)

     Tagged with:

     • Investigation
     • Recommendations
     • Surgery - Urology

   By Patient Safety Learning, 22 October, 2020

   • 0 comments
   • 94 views
   • 
   • Added by Patient Safety Learning
   • 22 October, 2020

8. HSIB: Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke (13 October 2020)

   • Investigation
   • Recommendations
   • (and 3 more)

     Tagged with:

     • Investigation
     • Recommendations
     • Stroke
     • Treatment
     • Patient harmed

   By Patient Safety Learning, 13 October, 2020

   • 0 comments
   • 131 views
   • 
   • Added by Patient Safety Learning
   • 13 October, 2020

9. HSIB: The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital (24 September 2020)

   • Adminstering medication
   • Investigation
   • (and 3 more)

     Tagged with:

     • Adminstering medication
     • Investigation
     • Patient death
     • Medicine - Clinical pharmacology
     • Older People (over 65)

   By Patient Safety Learning, 24 September, 2020

   • 0 comments
   • 385 views
   • 
   • Added by Patient Safety Learning
   • 24 September, 2020

10. National Learning Report. Giving families a voice: HSIB’s approach to patient and family engagement during investigations (17 September 2020)

    • Investigation
    • Patient / family involvement
    • (and 3 more)

      Tagged with:

      • Investigation
      • Patient / family involvement
      • Patient engagement
      • Feedback
      • Patient safety incident

    By Patient Safety Learning, 17 September, 2020

    • 0 comments
    • 168 views
    • 
    • Added by Patient Safety Learning
    • 17 September, 2020

11. HSIB National Intelligence Report. Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response (August 2020)

    • Virus
    • Infection control
    • (and 5 more)

      Tagged with:

      • Virus
      • Infection control
      • PPE (personal Protective Equipment)
      • Investigation
      • Recommendations
      • Care home
      • Patient death

    By Patient Safety Learning, 27 August, 2020

    • 0 comments
    • 424 views
    • 
    • Added by Patient Safety Learning
    • 27 August, 2020

12. Healthcare Safety Investigation Branch Annual Review 2019/20

    • Investigation
    • Recommendations
    • (and 1 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Patient safety incident

    By Sam, 15 August, 2020

    • 0 comments
    • 130 views
    • 
    • Added by Sam
    • 15 August, 2020

13. HSIB National Learning Report: Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection (July 2020)

    • Organisational learning
    • Maternity
    • (and 4 more)

      Tagged with:

      • Organisational learning
      • Maternity
      • Medicine - Infectious disease
      • Baby
      • Patient death
      • Medicine - Neurology

    By PatientSafetyLearning Team, 16 July, 2020

    • 0 comments
    • 433 views
    • 
    • Added by PatientSafetyLearning Team
    • 16 July, 2020

14. East Kent Hospitals maternity services: HSIB summary report (7 April 2020)

    • Investigation
    • Recommendations
    • (and 3 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Maternity
      • Patient death
      • Patient harmed

    By Patient Safety Learning, 8 April, 2020

    • 0 comments
    • 270 views
    • 
    • Added by Patient Safety Learning
    • 8 April, 2020

15. National learning report: summary of themes arising from the HSIB maternity programme (26 March 2020)

    • Safety report
    • Organisational learning
    • (and 2 more)

      Tagged with:

      • Safety report
      • Organisational learning
      • Obstetrics and gynaecology/ Maternity
      • Investigation

    By PatientSafetyLearning Team, 26 March, 2020

    • 0 comments
    • 222 views
    • 
    • Added by PatientSafetyLearning Team
    • 26 March, 2020

16. HSIB report: Undiagnosed cardiomyopathy in a young person with autism (19 March 2020)

    • Anaesthesia
    • Imaging
    • (and 3 more)

      Tagged with:

      • Anaesthesia
      • Imaging
      • Learning disorders
      • Autism
      • Investigation

    By Patient Safety Learning, 19 March, 2020

    • 0 comments
    • 235 views
    • 
    • Added by Patient Safety Learning
    • 19 March, 2020

17. HSIB report: The diagnosis of ectopic pregnancy (5 March 2020)

    • Pregnancy
    • Investigation
    • (and 1 more)

      Tagged with:

      • Pregnancy
      • Investigation
      • Diagnosis

    By Patient Safety Learning, 5 March, 2020

    • 0 comments
    • 271 views
    • 
    • Added by Patient Safety Learning
    • 5 March, 2020

18. HSIB report: Implantation of wrong prostheses during joint replacement surgery (June 2018)

    • Never event
    • Investigation
    • (and 3 more)

      Tagged with:

      • Never event
      • Investigation
      • Human error
      • Latent error
      • Surgery - Trauma and orthopaedic

    By Claire Cox, 24 February, 2020

    • 0 comments
    • 192 views
    • 
    • Added by Claire Cox
    • 24 February, 2020

19. HSIB report: Investigation into potential under-recognised risk of harm from the use of propranolol (6 February 2020)

    • Prescribing
    • Patient death
    • (and 3 more)

      Tagged with:

      • Prescribing
      • Patient death
      • Medication
      • Investigation
      • Recommendations

    By Sam, 6 February, 2020

    • 0 comments
    • 384 views
    • 
    • Added by Sam
    • 6 February, 2020

20. HSIB: Investigation into delayed recognition of acute aortic dissection (23 January 2020)

    • Accident and Emergency
    • Patient death
    • (and 5 more)

      Tagged with:

      • Accident and Emergency
      • Patient death
      • Perception / understanding
      • Investigation
      • Recommendations
      • Emergency medicine
      • Medicine - Cardiology

    By Patient Safety Learning, 23 January, 2020

    • 0 comments
    • 327 views
    • 
    • Added by Patient Safety Learning
    • 23 January, 2020

21. HSIB report: Recognising and responding to critically unwell patients (May 2019)

    • Deterioration
    • Observations
    • (and 5 more)

      Tagged with:

      • Deterioration
      • Observations
      • Monitoring
      • Emergency medicine
      • Accident and Emergency
      • Recommendations
      • Human error

    By PatientSafetyLearning Team, 14 January, 2020

    • 0 comments
    • 285 views
    • 
    • Added by PatientSafetyLearning Team
    • 14 January, 2020

22. HSIB report: Lack of timely monitoring of patients with glaucoma (9 January 2020)

    • Patient
    • Follow up
    • (and 4 more)

      Tagged with:

      • Patient
      • Follow up
      • Medicine - Ophthalmology
      • Patient harmed
      • Investigation
      • Long waiting list

    By Patient Safety Learning, 9 January, 2020

    • 1 comment
    • 507 views
    • 
    • Comment by PatientSafetyLearning Team
    • 9 January, 2020

23. Healthcare Safety Investigation Branch: Annual Review 2018/19

    • Information sharing
    • Personal reflection
    • (and 3 more)

      Tagged with:

      • Information sharing
      • Personal reflection
      • Evaluation
      • Policies / Protocols / Procedures
      • Investigation

    By Claire Cox, 20 December, 2019

    • 0 comments
    • 278 views
    • 
    • Added by Claire Cox
    • 20 December, 2019

24. HSIB report: Investigation into detection of retained vaginal swabs and tampons following childbirth (updated 15 July 2020)

    • Never event
    • Investigation
    • (and 2 more)

      Tagged with:

      • Never event
      • Investigation
      • Recommendations
      • Post partum

    By Patient Safety Learning, 19 December, 2019

    • 0 comments
    • 648 views
    • 
    • Added by Patient Safety Learning
    • 19 December, 2019

25. HSIB report: Investigation into electronic prescribing and medicines administration systems and safe discharge (October 2019)

    • Prescribing
    • Medicine - Clinical pharmacology
    • (and 2 more)

      Tagged with:

      • Prescribing
      • Medicine - Clinical pharmacology
      • Patient death
      • Adminstering medication

    By PatientSafetyLearning Team, 20 November, 2019

    • 0 comments
    • 474 views
    • 
    • Added by PatientSafetyLearning Team
    • 20 November, 2019