HSIB investigations

Articles in this category

1. HSIB: Detection of jaundice in newborn babies (26 January 2023)

   • Investigation
   • UK
   • (and 6 more)

     Tagged with:

     • Investigation
     • UK
     • Baby
     • Screening
     • Tests / investigations
     • Patient harmed
     • NICU/SCBU
     • Race

   By Patient-Safety-Learning, Yesterday at 10:44

   • 0 comments
   • 52 views
   • 
   • Added by Patient-Safety-Learning
   • Yesterday at 10:44

2. HSIB: Supporting NHS staff involved in patient safety investigations (19 December 2022)

   • Investigation
   • Staff support
   • (and 3 more)

     Tagged with:

     • Investigation
     • Staff support
     • Patient safety incident
     • Organisational learning
     • Psychological safety

   By Patient Safety Learning, 3 January

   • 0 comments
   • 203 views
   • 
   • Added by Patient Safety Learning
   • 3 January

3. HSIB: Safety investigation jargon buster

   • Investigation
   • Communication
   • (and 1 more)

     Tagged with:

     • Investigation
     • Communication
     • Patient safety incident

   By Patient Safety Learning, 21 December, 2022

   • 0 comments
   • 63 views
   • 
   • Added by Patient Safety Learning
   • 21 December, 2022

4. HSIB - The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period final report (8 December 2022)

   • Deep vein thrombosis
   • Pregnancy
   • (and 5 more)

     Tagged with:

     • Deep vein thrombosis
     • Pregnancy
     • Maternity
     • Post partum
     • Diagnosis
     • Medication
     • Patient harmed

   By Patient-Safety-Learning, 8 December, 2022

   • 0 comments
   • 171 views
   • 
   • Added by Patient-Safety-Learning
   • 8 December, 2022

5. Harmed Patient Safety Governance role: An open letter from a patient safety campaigner

   • Patient engagement
   • Patient / family involvement
   • (and 2 more)

     Tagged with:

     • Patient engagement
     • Patient / family involvement
     • Investigation
     • Patient harmed

   By richard vA, 30 November, 2022

   • 1 comment
   • 174 views
   • 
   • Comment by richard vA
   • 6 January

6. HSIB - Clinical investigation booking systems failures interim report (24 November 2022)

   • Appointment
   • Electronic Health Record
   • (and 6 more)

     Tagged with:

     • Appointment
     • Electronic Health Record
     • Imaging
     • Communication
     • Diagnosis
     • Diagnostic error
     • England
     • Cancer

   By Patient-Safety-Learning, 24 November, 2022

   • 0 comments
   • 91 views
   • 
   • Added by Patient-Safety-Learning
   • 24 November, 2022

7. HSIB interim bulletin - Harm caused by delays in transferring patients to the right place of care (3 November 2022)

   • Ambulance
   • Handover
   • (and 6 more)

     Tagged with:

     • Ambulance
     • Handover
     • Emergency medicine
     • Accident and Emergency
     • Deterioration
     • Patient harmed
     • Investigation
     • England

   By Patient-Safety-Learning, 3 November, 2022

   • 0 comments
   • 160 views
   • 
   • Added by Patient-Safety-Learning
   • 3 November, 2022

8. Healthcare Safety Investigations Conference 2022: presentations and videos (21 September 2022)

   • Investigation
   • System safety
   • (and 4 more)

     Tagged with:

     • Investigation
     • System safety
     • Maternity
     • Medication
     • Patient safety incident
     • Patient harmed

   By Patient Safety Learning, 28 October, 2022

   • 0 comments
   • 259 views
   • 
   • Added by Patient Safety Learning
   • 28 October, 2022

9. HSIB’s local investigation pilot: shared learning for local healthcare systems (13 October 2022)

   • Investigation
   • Innovation
   • (and 6 more)

     Tagged with:

     • Investigation
     • Innovation
     • Patient identification
     • Handover
     • Emergency medicine
     • Integrated Care System (ICS)
     • England
     • Organisational learning

   By Patient-Safety-Learning, 13 October, 2022

   • 0 comments
   • 270 views
   • 
   • Added by Patient-Safety-Learning
   • 13 October, 2022

10. HSIB investigation: NHS 111’s response to callers with Covid-19-related symptoms during the pandemic (29 September 2022)

    • Pandemic
    • Telemedicine
    • (and 6 more)

      Tagged with:

      • Pandemic
      • Telemedicine
      • Emergency medicine
      • Symptoms
      • Diagnostic error
      • Diagnosis
      • Patient death
      • Underlying health conditions

    By Patient-Safety-Learning, 29 September, 2022

    • 0 comments
    • 1,762 views
    • 
    • Added by Patient-Safety-Learning
    • 29 September, 2022

11. HSIB - Management of preterm labour and birth of twins (25 August 2022)

    • Baby
    • Labour
    • (and 7 more)

      Tagged with:

      • Baby
      • Labour
      • NICU/SCBU
      • Maternity
      • Paediatrics
      • Patient
      • Research
      • Knowledge issue
      • Monitoring

    By Patient-Safety-Learning, 6 September, 2022

    • 0 comments
    • 2,938 views
    • 
    • Added by Patient-Safety-Learning
    • 6 September, 2022

12. HSIB: The use of an appropriate flush fluid with arterial lines (11 August 2022)

    • Investigation
    • More staff training
    • (and 6 more)

      Tagged with:

      • Investigation
      • More staff training
      • Recommendations
      • Medication - related
      • Human factors
      • Human error
      • HDU / ICU
      • Patient safety incident

    By Patient Safety Learning, 16 August, 2022

    • 0 comments
    • 393 views
    • 
    • Added by Patient Safety Learning
    • 16 August, 2022

13. HSIB maternity investigation programme year in review 2021/22 (4 August 2022)

    • Investigation
    • Maternity
    • (and 3 more)

      Tagged with:

      • Investigation
      • Maternity
      • Recommendations
      • Patient / family involvement
      • Patient / family support

    By Patient Safety Learning, 5 August, 2022

    • 0 comments
    • 308 views
    • 
    • Added by Patient Safety Learning
    • 5 August, 2022

14. HSIB: Administering high-strength insulin from a pen device in hospital (7 July 2022)

    • Investigation
    • Diabetes
    • (and 7 more)

      Tagged with:

      • Investigation
      • Diabetes
      • Standards
      • Staff factors
      • More staff training
      • Recommendations
      • Adminstering medication
      • Medication
      • Medical device

    By Patient Safety Learning, 7 July, 2022

    • 0 comments
    • 388 views
    • 
    • Added by Patient Safety Learning
    • 7 July, 2022

15. HSIB: Medicine omissions in learning disability secure units (23 June 2022)

    • Learning disabilities
    • Medication
    • (and 6 more)

      Tagged with:

      • Learning disabilities
      • Medication
      • Patient harmed
      • Mental health unit
      • Nurse
      • Communication
      • Patient engagement
      • Diabetes

    By Patient-Safety-Learning, 23 June, 2022

    • 0 comments
    • 434 views
    • 
    • Added by Patient-Safety-Learning
    • 23 June, 2022

16. HSIB: Harm caused by delays in transferring patients to the right place of care (16 June 2022)

    • Transfer of care
    • Emergency medicine
    • (and 5 more)

      Tagged with:

      • Transfer of care
      • Emergency medicine
      • Investigation
      • Communication
      • Discharge
      • Deterioration
      • Ambulance

    By Patient-Safety-Learning, 16 June, 2022

    • 0 comments
    • 429 views
    • 
    • Added by Patient-Safety-Learning
    • 16 June, 2022

17. HSIB: Decontamination of surgical instruments (26 May 2022)

    • Infection control
    • Medical device / equipment
    • (and 4 more)

      Tagged with:

      • Infection control
      • Medical device / equipment
      • Infrastructure / building / equipment
      • Surgery - General
      • Reporting
      • Regulatory issue

    By Patient-Safety-Learning, 26 May, 2022

    • 0 comments
    • 416 views
    • 
    • Added by Patient-Safety-Learning
    • 26 May, 2022

18. HSIB: Unintentional overdose of morphine sulfate oral solution (28 April 2022)

    • Medication
    • Patient death
    • (and 4 more)

      Tagged with:

      • Medication
      • Patient death
      • Pain
      • Prescribing
      • Adminstering medication
      • Investigation

    By Patient-Safety-Learning, 28 April, 2022

    • 0 comments
    • 344 views
    • 
    • Added by Patient-Safety-Learning
    • 28 April, 2022

19. HSIB: Provision of care for children and young people when accessing specialist gender dysphoria services (7 April 2022)

    • Investigation
    • LGBTQI
    • (and 6 more)

      Tagged with:

      • Investigation
      • LGBTQI
      • Adolescent
      • Mental health
      • Mental health - CAMHS
      • Recommendations
      • Children and Young People
      • Organisation / service factors

    By Patient Safety Learning, 7 April, 2022

    • 0 comments
    • 569 views
    • 
    • Added by Patient Safety Learning
    • 7 April, 2022

20. HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)

    • Emergency medicine
    • Accident and Emergency
    • (and 5 more)

      Tagged with:

      • Emergency medicine
      • Accident and Emergency
      • Diagnosis
      • Investigation
      • Training
      • Decision making
      • Imaging

    By Patient-Safety-Learning, 24 March, 2022

    • 0 comments
    • 498 views
    • 
    • Added by Patient-Safety-Learning
    • 24 March, 2022

21. HSIB: Local integrated investigation pilot 3 - Transfer of a patient who had suffered a stroke to emergency care (17 March 2022)

    • Stroke
    • Emergency medicine
    • (and 4 more)

      Tagged with:

      • Stroke
      • Emergency medicine
      • Accident and Emergency
      • Transfer of care
      • Older People (over 65)
      • Flawed processes

    By Patient-Safety-Learning, 17 March, 2022

    • 0 comments
    • 500 views
    • 
    • Added by Patient-Safety-Learning
    • 17 March, 2022

22. HSIB: Emergency neonatal blood transfusion at birth following acute blood loss during and/or delivery (3 March 2022)

    • Blood / blood products
    • NICU/SCBU
    • (and 4 more)

      Tagged with:

      • Blood / blood products
      • NICU/SCBU
      • Baby
      • Resuscitation
      • Communication
      • Patient death

    By Patient-Safety-Learning, 3 March, 2022

    • 0 comments
    • 354 views
    • 
    • Added by Patient-Safety-Learning
    • 3 March, 2022

23. HSIB: Unintentional overdose of paracetamol in adults with low bodyweight (24 February 2022)

    • Medication
    • Adminstering medication
    • (and 4 more)

      Tagged with:

      • Medication
      • Adminstering medication
      • Patient harmed
      • Pain
      • Older People (over 65)
      • Hospital ward

    By Patient-Safety-Learning, 24 February, 2022

    • 0 comments
    • 518 views
    • 
    • Added by Patient-Safety-Learning
    • 24 February, 2022

24. HSIB: Maternity pre-arrival instructions by 999 call handlers (17 February 2022)

    • Maternity
    • Pregnancy
    • (and 5 more)

      Tagged with:

      • Maternity
      • Pregnancy
      • Baby
      • Emergency medicine
      • Obstetrics and gynaecology/ Maternity
      • Communication
      • NICU/SCBU

    By Mark Hughes, 17 February, 2022

    • 0 comments
    • 660 views
    • 
    • Added by Mark Hughes
    • 17 February, 2022

25. HSIB: Sharing learning for shared care (28 January 2022)

    • Investigation
    • Private sector
    • (and 5 more)

      Tagged with:

      • Investigation
      • Private sector
      • Collaboration
      • Healthcare
      • Information sharing
      • Organisational learning
      • Surgery - General

    By Patient Safety Learning, 4 February, 2022

    • 0 comments
    • 827 views
    • 
    • Added by Patient Safety Learning
    • 4 February, 2022