HSIB investigations

Articles in this category

1. 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, July 16

   • 0 comments
   • 227 views
   • 
   • Added by PatientSafetyLearning Team
   • July 16

2. 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, April 8

   • 0 comments
   • 175 views
   • 
   • Added by Patient Safety Learning
   • April 8

3. Giving families a voice: HSIB’s approach to family engagement during investigations

   • Investigation
   • Maternity
   • (and 2 more)

     Tagged with:

     • Investigation
     • Maternity
     • Patient / family involvement
     • Recommendations

   By Sam, March 31

   • 0 comments
   • 189 views
   • 
   • Added by Sam
   • March 31

4. 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, March 26

   • 0 comments
   • 126 views
   • 
   • Added by PatientSafetyLearning Team
   • March 26

5. 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, March 19

   • 0 comments
   • 169 views
   • 
   • Added by Patient Safety Learning
   • March 19

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

   • Pregnancy
   • Investigation
   • (and 1 more)

     Tagged with:

     • Pregnancy
     • Investigation
     • Diagnosis

   By Patient Safety Learning, March 5

   • 0 comments
   • 174 views
   • 
   • Added by Patient Safety Learning
   • March 5

7. 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, February 24

   • 0 comments
   • 118 views
   • 
   • Added by Claire Cox
   • February 24

8. 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, February 6

   • 0 comments
   • 286 views
   • 
   • Added by Sam
   • February 6

9. 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, January 23

   • 0 comments
   • 224 views
   • 
   • Added by Patient Safety Learning
   • January 23

10. 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, January 14

    • 0 comments
    • 174 views
    • 
    • Added by PatientSafetyLearning Team
    • January 14

11. 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, January 9

    • 1 comment
    • 323 views
    • 
    • Comment by PatientSafetyLearning Team
    • January 9

12. 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, December 20, 2019

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

13. HSIB report: Investigation into detection of retained vaginal swabs and tampons following childbirth (18 December 2019)

    • Never event
    • Investigation
    • (and 2 more)

      Tagged with:

      • Never event
      • Investigation
      • Recommendations
      • Post partum

    By Patient Safety Learning, December 19, 2019

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

14. 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, November 20, 2019

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

15. HSIB presentation at the Patient Safety Strategy Discussion Forum (18 November 2019)

    • Patient safety incident
    • Investigation
    • (and 1 more)

      Tagged with:

      • Patient safety incident
      • Investigation
      • Methodology

    By Patient Safety Learning, November 18, 2019

    • 0 comments
    • 162 views
    • 
    • Added by Patient Safety Learning
    • November 18, 2019

16. HSIB report: Electronic prescribing and medicines administration systems and safe discharge (24 October 2019)

    • Prescribing
    • Investigation
    • (and 4 more)

      Tagged with:

      • Prescribing
      • Investigation
      • Pharmacist
      • Transfer of care
      • Medication
      • Digital health

    By Patient Safety Learning, October 24, 2019

    • 0 comments
    • 593 views
    • 
    • Added by Patient Safety Learning
    • October 24, 2019

17. HSIB report: Investigation into management of chronic health conditions in prisons (10 October 2019)

    • Prison
    • Prison warden
    • (and 4 more)

      Tagged with:

      • Prison
      • Prison warden
      • Patient
      • Transfer of care
      • Treatment
      • Medication

    By Patient Safety Learning, October 14, 2019

    • 0 comments
    • 284 views
    • 
    • Added by Patient Safety Learning
    • October 14, 2019

18. HSIB report: Investigation into wrong patient details on blood sample (26 September 2019)

    • Near miss
    • Blood / blood products
    • (and 4 more)

      Tagged with:

      • Near miss
      • Blood / blood products
      • Orders / requests
      • Human error
      • Fatigue / exhaustion
      • Investigation

    By Patient Safety Learning, September 26, 2019

    • 0 comments
    • 206 views
    • 
    • Added by Patient Safety Learning
    • September 26, 2019

19. HSIB report: Management of acute onset testicular pain (12 September 2019)

    By Claire Cox, September 12, 2019

    • 0 comments
    • 223 views
    • 
    • Added by Claire Cox
    • September 12, 2019

20. HSIB Interim bulletin: identifying and reducing high-risk prescribing errors in hospital (22 July 2019)

    • Older People (over 65)
    • Investigation
    • (and 4 more)

      Tagged with:

      • Older People (over 65)
      • Investigation
      • Patient harmed
      • Medication
      • Prescribing
      • Hospital ward

    By Patient Safety Learning, July 26, 2019

    • 0 comments
    • 320 views
    • 
    • Added by Patient Safety Learning
    • July 26, 2019

21. HSIB report: Investigation into failures in communication or follow-up of unexpected significant radiological findings (July 2019)

    • Radiologist
    • Diagnosis
    • (and 5 more)

      Tagged with:

      • Radiologist
      • Diagnosis
      • Medicine - Oncology
      • Patient death
      • Communication problems
      • Cancer
      • Investigation

    By Patient Safety Learning, July 19, 2019

    • 0 comments
    • 426 views
    • 
    • Added by Patient Safety Learning
    • July 19, 2019

22. HSIB report: Inadvertent administration of an oral liquid medicine into a vein (April 2019)

    • Medication
    • Prescribing
    • (and 9 more)

      Tagged with:

      • Medication
      • Prescribing
      • Doctor
      • Nurse
      • Patient
      • Near miss
      • Human error
      • System safety
      • Process redesign
      • Investigation
      • Risk management

    By Patient Safety Learning, June 26, 2019

    • 0 comments
    • 201 views
    • 
    • Added by Patient Safety Learning
    • June 26, 2019

23. HSIB report: Insertion of an incorrect intraocular lens (update November 2018)

    • Medicine - Ophthalmology
    • Medical device / equipment
    • (and 5 more)

      Tagged with:

      • Medicine - Ophthalmology
      • Medical device / equipment
      • Readmission
      • Safety assessment
      • Investigation
      • Recommendations
      • Near miss

    By Patient Safety Learning, June 26, 2019

    • 0 comments
    • 187 views
    • 
    • Added by Patient Safety Learning
    • June 26, 2019

24. HSIB interim bulletin: The diagnosis of ectopic pregnancy (7 November 2018)

    • Diagnosis
    • Obstetrics and gynaecology/ Maternity
    • (and 6 more)

      Tagged with:

      • Diagnosis
      • Obstetrics and gynaecology/ Maternity
      • Clinical process
      • Patient harmed
      • Additional treatment / tests
      • Investigation
      • Recommendations
      • Out-patient midwifery services

    By Patient Safety Learning, June 26, 2019

    • 0 comments
    • 256 views
    • 
    • Added by Patient Safety Learning
    • June 26, 2019

25. HSIB report: Investigation into the design and safe use of portable oxygen systems (November 2018)

    • Investigation
    • Risk management
    • (and 4 more)

      Tagged with:

      • Investigation
      • Risk management
      • Recommendations
      • Medicine - Respiratory
      • Emergency medicine
      • Oxygen / gas / vapour

    By Patient Safety Learning, June 26, 2019

    • 0 comments
    • 206 views
    • 
    • Added by Patient Safety Learning
    • June 26, 2019