HSIB investigations

Articles in this category

1. 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

   • 0 comments
   • 62 views
   • 
   • Added by Patient-Safety-Learning
   • 28 April

2. 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

   • 0 comments
   • 147 views
   • 
   • Added by Patient Safety Learning
   • 7 April

3. 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

   • 0 comments
   • 190 views
   • 
   • Added by Patient-Safety-Learning
   • 24 March

4. 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

   • 0 comments
   • 205 views
   • 
   • Added by Patient-Safety-Learning
   • 17 March

5. 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

   • 0 comments
   • 156 views
   • 
   • Added by Patient-Safety-Learning
   • 3 March

6. 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

   • 0 comments
   • 205 views
   • 
   • Added by Patient-Safety-Learning
   • 24 February

7. 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

   • 0 comments
   • 280 views
   • 
   • Added by Mark Hughes
   • 17 February

8. 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

   • 0 comments
   • 337 views
   • 
   • Added by Patient Safety Learning
   • 4 February

9. HSIB: Weight-based medication errors in children (3 February 2022)

   • Medication
   • Children and Young People
   • (and 2 more)

     Tagged with:

     • Medication
     • Children and Young People
     • Patient harmed
     • Safety report

   By Patient-Safety-Learning, 3 February

   • 0 comments
   • 241 views
   • 
   • Added by Patient-Safety-Learning
   • 3 February

10. HSIB: Local integrated investigation pilot 2. Incorrect patient details handover (20 January 2022)

    • Investigation
    • Care record
    • (and 5 more)

      Tagged with:

      • Investigation
      • Care record
      • Care navigation
      • Care coordination
      • Handover
      • Accident and Emergency
      • Discharge

    By Patient Safety Learning, 21 January

    • 0 comments
    • 455 views
    • 
    • Added by Patient Safety Learning
    • 21 January

11. HSIB: Recognition of the acutely ill infant (9 December 2021)

    • Investigation
    • Children and Young People
    • (and 10 more)

      Tagged with:

      • Investigation
      • Children and Young People
      • Medicine - Infectious disease
      • Sepsis
      • Virus
      • Patient death
      • Patient / family involvement
      • Symptoms
      • Staff support
      • Training
      • Ambulance
      • Health inequalities

    By Patient Safety Learning, 9 December, 2021

    • 0 comments
    • 608 views
    • 
    • Added by Patient Safety Learning
    • 9 December, 2021

12. HSIB: Local integrated investigation pilot 1. Incorrect patient identification (25 November 2021)

    • Investigation
    • Ambulance
    • (and 6 more)

      Tagged with:

      • Investigation
      • Ambulance
      • Patient
      • Human error
      • Medication
      • Patient / family involvement
      • Emergency medicine
      • Care record

    By Patient Safety Learning, 25 November, 2021

    • 0 comments
    • 327 views
    • 
    • Added by Patient Safety Learning
    • 25 November, 2021

13. HSIB: Treating COVID-19 patients using continuous positive airway pressure (CPAP) outside of a critical care unit (18 November 2021)

    • Pandemic
    • Medicine - Respiratory
    • (and 3 more)

      Tagged with:

      • Pandemic
      • Medicine - Respiratory
      • Virus
      • Investigation
      • Recommendations

    By Patient Safety Learning, 18 November, 2021

    • 0 comments
    • 343 views
    • 
    • Added by Patient Safety Learning
    • 18 November, 2021

14. HSIB: Surgical care of NHS patients in independent hospitals (28 October 2021)

    • Surgery - General
    • Private sector
    • (and 4 more)

      Tagged with:

      • Surgery - General
      • Private sector
      • Pre-op period
      • Pandemic
      • Post-op period
      • Recommendations

    By Mark Hughes, 28 October, 2021

    • 0 comments
    • 379 views
    • 
    • Added by Mark Hughes
    • 28 October, 2021

15. Healthcare Safety Investigation Conference: presentations and resources (15 October 2021)

    • Investigation
    • Patient safety incident
    • (and 4 more)

      Tagged with:

      • Investigation
      • Patient safety incident
      • Training
      • Pandemic
      • Maternity
      • Patient / family involvement

    By Patient Safety Learning, 20 October, 2021

    • 0 comments
    • 470 views
    • 
    • Added by Patient Safety Learning
    • 20 October, 2021

16. HSIB Maternity newsletter (May 2021)

    • Investigation
    • Recommendations
    • (and 4 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Maternity
      • Baby
      • Pregnancy
      • Risk assessment

    By Patient Safety Learning, 18 October, 2021

    • 0 comments
    • 96 views
    • 
    • Added by Patient Safety Learning
    • 18 October, 2021

17. HSIB report: Missed detection of lung cancer on chest X-rays of patients being seen in primary care (14 October 2021)

    • AI
    • Cancer
    • (and 4 more)

      Tagged with:

      • AI
      • Cancer
      • Diagnosis
      • Screening
      • Diagnostic error
      • Radiology

    By Patient-Safety-Learning, 14 October, 2021

    • 0 comments
    • 340 views
    • 
    • Added by Patient-Safety-Learning
    • 14 October, 2021

18. Quality insights and safety improvements in maternity care (HSIB workshop, 16 September 2021)

    • Quality improvement
    • Maternity
    • (and 1 more)

      Tagged with:

      • Quality improvement
      • Maternity
      • Investigation

    By Patient Safety Learning, 10 October, 2021

    • 0 comments
    • 169 views
    • 
    • Added by Patient Safety Learning
    • 10 October, 2021

19. COVID-19 related national investigations and reports (HSIB workshop, 16 September 2021)

    • Investigation
    • Virus
    • (and 1 more)

      Tagged with:

      • Investigation
      • Virus
      • Pandemic

    By Patient Safety Learning, 10 October, 2021

    • 0 comments
    • 167 views
    • 
    • Added by Patient Safety Learning
    • 10 October, 2021

20. HSIB National Learning Report. Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic, 1 April to 30 June 2020

    • Investigation
    • Maternity
    • (and 4 more)

      Tagged with:

      • Investigation
      • Maternity
      • Labour
      • Recommendations
      • Staff factors
      • Pandemic

    By Patient Safety Learning, 16 September, 2021

    • 0 comments
    • 499 views
    • 
    • Added by Patient Safety Learning
    • 16 September, 2021

21. A thematic analysis of HSIB's first 22 national investigations (September 2021)

    • Investigation
    • Patient safety incident

    By Patient Safety Learning, 9 September, 2021

    • 0 comments
    • 854 views
    • 
    • Added by Patient Safety Learning
    • 9 September, 2021

22. HSIB: A simple overview (27 July 2021)

    • Investigation

    By Patient Safety Learning, 7 September, 2021

    • 0 comments
    • 252 views
    • 
    • Added by Patient Safety Learning
    • 7 September, 2021

23. HSIB: Timely detection and treatment of cauda equina syndrome (19 August 2021)

    • Investigation
    • Surgery - General
    • (and 1 more)

      Tagged with:

      • Investigation
      • Surgery - General
      • Diagnosis

    By Mark Hughes, 23 August, 2021

    • 0 comments
    • 438 views
    • 
    • Added by Mark Hughes
    • 23 August, 2021

24. HSIB maternity programme year in review 2020/21 (August 2021)

    • Investigation
    • Maternity
    • (and 3 more)

      Tagged with:

      • Investigation
      • Maternity
      • Patient death
      • Recommendations
      • Patient safety incident

    By Mark Hughes, 18 August, 2021

    • 0 comments
    • 462 views
    • 
    • Added by Mark Hughes
    • 18 August, 2021

25. HSIB: Suitability of equipment and technology used for continuous fetal heart rate monitoring (July 2021)

    • Investigation
    • Complaint
    • (and 3 more)

      Tagged with:

      • Investigation
      • Complaint
      • Medical device / equipment
      • Pregnancy
      • Medicine - Cardiology

    By Patient-Safety-Learning, 16 July, 2021

    • 0 comments
    • 472 views
    • 
    • Added by Patient-Safety-Learning
    • 16 July, 2021