HSIB investigations

Articles in this category

1. 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, Thursday at 08:44

   • 0 comments
   • 106 views
   • 
   • Added by Patient-Safety-Learning
   • Thursday at 08:44

2. 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

   • 0 comments
   • 171 views
   • 
   • Added by Patient Safety Learning
   • 16 September

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

   • Investigation
   • Patient safety incident

   By Patient Safety Learning, 9 September

   • 0 comments
   • 445 views
   • 
   • Added by Patient Safety Learning
   • 9 September

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

   • Investigation

   By Patient Safety Learning, 7 September

   • 0 comments
   • 86 views
   • 
   • Added by Patient Safety Learning
   • 7 September

5. 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

   • 0 comments
   • 168 views
   • 
   • Added by Mark Hughes
   • 23 August

6. 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

   • 0 comments
   • 215 views
   • 
   • Added by Mark Hughes
   • 18 August

7. 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

   • 0 comments
   • 263 views
   • 
   • Added by Patient-Safety-Learning
   • 16 July

8. HSIB: Wrong site surgery – wrong patient: invasive procedures in outpatient settings (June 2021)

   • Investigation
   • Womens health
   • (and 4 more)

     Tagged with:

     • Investigation
     • Womens health
     • Patient harmed
     • Outpatients
     • Appointment
     • Surgery - General

   By Patient Safety Learning, 3 June

   • 0 comments
   • 325 views
   • 
   • Added by Patient Safety Learning
   • 3 June

9. HSIB webinar: Management of chronic asthma management (20 May 2021)

   • Asthma
   • Investigation
   • (and 2 more)

     Tagged with:

     • Asthma
     • Investigation
     • Medicine - Respiratory
     • Children and Young People

   By Patient Safety Learning, 24 May

   • 0 comments
   • 172 views
   • 
   • Added by Patient Safety Learning
   • 24 May

10. Piped supply of medical air and oxygen (HSIB investigation)

    • Medicine - Respiratory
    • Patient death
    • (and 1 more)

      Tagged with:

      • Medicine - Respiratory
      • Patient death
      • Investigation

    By PatientSafetyLearning Team, 12 May

    • 0 comments
    • 163 views
    • 
    • Added by PatientSafetyLearning Team
    • 12 May

11. HSIB: Management of chronic asthma in children aged 16 years and under (May 2021)

    • Asthma
    • Investigation
    • (and 1 more)

      Tagged with:

      • Asthma
      • Investigation
      • Children and Young People

    By Patient Safety Learning, 5 May

    • 0 comments
    • 257 views
    • 
    • Added by Patient Safety Learning
    • 5 May

12. HSIB: Outpatient appointments intended but not booked after inpatient stays (29 April 2021)

    • Investigation
    • Outpatients
    • (and 2 more)

      Tagged with:

      • Investigation
      • Outpatients
      • Follow up
      • Appointment

    By Patient Safety Learning, 30 April

    • 0 comments
    • 194 views
    • 
    • Added by Patient Safety Learning
    • 30 April

13. HSIB investigation: Wrong site surgery - wrong tooth extraction (22 April 2021)

    • Dentist
    • Investigation
    • (and 5 more)

      Tagged with:

      • Dentist
      • Investigation
      • Surgery - General
      • Aviation
      • Private sector
      • Patient safety incident
      • Risk management

    By Patient Safety Learning, 27 April

    • 0 comments
    • 242 views
    • 
    • Added by Patient Safety Learning
    • 27 April

14. HSIB Interim bulletin: surgical care of NHS patients in independent hospitals (April 2021)

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

      Tagged with:

      • Investigation
      • Surgery - General
      • Private sector

    By Patient Safety Learning, 20 April

    • 0 comments
    • 221 views
    • 
    • Added by Patient Safety Learning
    • 20 April

15. HSIB: Emergency response to heart attack. Summary report (March 2021)

    • Heart disease
    • Investigation
    • (and 3 more)

      Tagged with:

      • Heart disease
      • Investigation
      • Recommendations
      • Ambulance
      • Emergency medicine

    By Patient Safety Learning, 15 March

    • 0 comments
    • 176 views
    • 
    • Added by Patient Safety Learning
    • 15 March

16. HSIB: Residual drugs in intravenous cannulae and extension lines (March 2021)

    • Investigation
    • Surgery - General
    • (and 3 more)

      Tagged with:

      • Investigation
      • Surgery - General
      • Anaesthesia
      • Medication
      • Patient harmed

    By Patient Safety Learning, 4 March

    • 0 comments
    • 274 views
    • 
    • Added by Patient Safety Learning
    • 4 March

17. HSIB. Maternal death: learning from maternal death investigations during the first wave of the COVID-19 pandemic (February 2021)

    • Investigation
    • Maternity
    • (and 6 more)

      Tagged with:

      • Investigation
      • Maternity
      • Patient death
      • Virus
      • Secondary impact
      • Pandemic
      • Recommendations
      • Patient safety incident

    By Patient Safety Learning, 25 February

    • 0 comments
    • 404 views
    • 
    • Added by Patient Safety Learning
    • 25 February

18. HSIB National Learning Report: Severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia (4 February 2021)

    • Organisational learning
    • Baby
    • (and 3 more)

      Tagged with:

      • Organisational learning
      • Baby
      • Obstetrics and gynaecology/ Maternity
      • Patient harmed
      • Patient death

    By Patient Safety Learning, 4 February

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

19. HSIB: Oxygen issues during COVID-19 pandemic

    • Investigation
    • Oxygen / gas / vapour
    • (and 2 more)

      Tagged with:

      • Investigation
      • Oxygen / gas / vapour
      • Virus
      • Pandemic

    By Patient Safety Learning, 28 January

    • 0 comments
    • 275 views
    • 
    • Added by Patient Safety Learning
    • 28 January

20. 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, 21 January

    • 0 comments
    • 656 views
    • 
    • Added by PatientSafetyLearning Team
    • 21 January

21. 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
    • 397 views
    • 
    • Added by Patient Safety Learning
    • 17 December, 2020

22. 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
    • 379 views
    • 
    • Added by Patient Safety Learning
    • 3 December, 2020

23. 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
    • 374 views
    • 
    • Added by Patient Safety Learning
    • 12 November, 2020

24. 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
    • 156 views
    • 
    • Added by PatientSafetyLearning Team
    • 9 November, 2020

25. 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
    • 365 views
    • 
    • Added by Patient Safety Learning
    • 29 October, 2020