HSSIB investigations

Articles in this category

1. HSSIB Interim report: Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports (7 December 2023)

   • Medical device / equipment
   • Surgery - General
   • (and 3 more)

     Tagged with:

     • Medical device / equipment
     • Surgery - General
     • Patient safety incident
     • Investigation
     • Never event

   By Patient Safety Learning, Yesterday at 11:26

   • 0 comments
   • 80 views
   • 
   • Added by Patient Safety Learning
   • Yesterday at 11:26

2. HSSIB investigation. Continuity of care: delayed diagnosis in GP practices (30 November 2023)

   • Investigation
   • Diagnosis
   • (and 7 more)

     Tagged with:

     • Investigation
     • Diagnosis
     • GP
     • Care coordination
     • Information sharing
     • GP practice
     • Recommendations
     • Workload analysis
     • Electronic Health Record

   By Patient Safety Learning, 30 November

   • 0 comments
   • 59 views
   • 
   • Added by Patient Safety Learning
   • 30 November

3. HSSIB: Risks to medication delivery using ambulatory infusion pumps – design and usability in inpatient settings (15 November 2023)

   • Adminstering medication
   • Medication
   • (and 6 more)

     Tagged with:

     • Adminstering medication
     • Medication
     • Monitoring
     • Patient death
     • Investigation
     • Medical device / equipment
     • Medicine - Palliative
     • Human factors

   By Patient Safety Learning, 16 November

   • 0 comments
   • 143 views
   • 
   • Added by Patient Safety Learning
   • 16 November

4. The launch of HSSIB and its priorities for the future: a recent discussion at the Patient Safety Management Network

   • Investigation
   • Transparency
   • (and 6 more)

     Tagged with:

     • Investigation
     • Transparency
     • Organisational learning
     • Patient / family involvement
     • Safety management
     • System safety
     • Collaboration
     • Patient safety incident

   By Patient Safety Learning, 2 November

   • 0 comments
   • 605 views
   • 
   • Added by Patient Safety Learning
   • 2 November

5. HSSIB: Caring for adults with a learning disability in acute hospitals (2 November 2023)

   • Investigation
   • Patient death
   • (and 10 more)

     Tagged with:

     • Investigation
     • Patient death
     • Learning disabilities
     • Training
     • Electronic Health Record
     • Care coordination
     • Adult
     • Information sharing
     • Hospital ward
     • Standards
     • Health inequalities
     • Skill-based issue

   By Patient Safety Learning, 2 November

   • 0 comments
   • 231 views
   • 
   • Added by Patient Safety Learning
   • 2 November

6. Safety management systems: an introduction for healthcare (HSSIB, 18 October 2023)

   • Investigation
   • System safety
   • (and 5 more)

     Tagged with:

     • Investigation
     • System safety
     • Safety management
     • Risk management
     • Aviation
     • Regulatory issue
     • Recommendations

   By Patient Safety Learning, 18 October

   • 0 comments
   • 635 views
   • 
   • Added by Patient Safety Learning
   • 18 October

7. HSIB final report: Harm caused by delays in transferring patients to the right place of care (24 August 2023)

   • Transfer of care
   • Ambulance
   • (and 3 more)

     Tagged with:

     • Transfer of care
     • Ambulance
     • Accountability
     • Emergency medicine
     • Accident and Emergency

   By Patient-Safety-Learning, 24 August

   • 0 comments
   • 870 views
   • 
   • Added by Patient-Safety-Learning
   • 24 August

8. HSIB maternity investigation programme year in review 2022/23 (3 August 2023)

   • Investigation
   • Maternity
   • (and 3 more)

     Tagged with:

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

   By Mark Hughes, 3 August

   • 0 comments
   • 219 views
   • 
   • Added by Mark Hughes
   • 3 August

9. HSIB Annual Review 2022/23 (1 August 2023)

   • Investigation
   • Recommendations

   By Mark Hughes, 3 August

   • 0 comments
   • 248 views
   • 
   • Added by Mark Hughes
   • 3 August

10. HSIB: The selection and insertion of vascular grafts in haemodialysis patients (27 July 2023)

    • Investigation
    • Medical device
    • (and 9 more)

      Tagged with:

      • Investigation
      • Medical device
      • Packaging/ labelling/ signage
      • Surgery - Vascular
      • Human factors
      • Patient harmed
      • Safety culture
      • Standards
      • Checklists
      • Technology
      • System safety

    By Patient Safety Learning, 27 July

    • 0 comments
    • 203 views
    • 
    • Added by Patient Safety Learning
    • 27 July

11. HSIB: Variations in the delivery of palliative care services to adults (13 July 2023)

    • Investigation
    • Medicine - Palliative
    • (and 5 more)

      Tagged with:

      • Investigation
      • Medicine - Palliative
      • End of life care
      • Cancer
      • Organisation / service factors
      • Integrated Care System (ICS)
      • Adult

    By Patient Safety Learning, 13 July

    • 0 comments
    • 292 views
    • 
    • Added by Patient Safety Learning
    • 13 July

12. HSIB: Invasive procedures for patients with sickle cell disease (22 June 2023)

    • Investigation
    • Sickle cell
    • (and 4 more)

      Tagged with:

      • Investigation
      • Sickle cell
      • Medicine - Haematology
      • Patient harmed
      • Information sharing
      • Surgery - General

    By Patient Safety Learning, 22 June

    • 0 comments
    • 228 views
    • 
    • Added by Patient Safety Learning
    • 22 June

13. HSIB: Management of sickle cell crisis (22 June 2023)

    • Sickle cell
    • Investigation
    • (and 3 more)

      Tagged with:

      • Sickle cell
      • Investigation
      • Training
      • Skills gap
      • Patient death

    By Patient Safety Learning, 22 June

    • 0 comments
    • 285 views
    • 
    • Added by Patient Safety Learning
    • 22 June

14. HSIB interim report. Keeping children and young people with mental health needs safe: the design of the paediatric ward (25 May 2023)

    • Investigation
    • Paediatrics
    • (and 4 more)

      Tagged with:

      • Investigation
      • Paediatrics
      • Hospital ward
      • Mental health
      • Children and Young People
      • Organisation / service factors

    By Patient Safety Learning, 25 May

    • 0 comments
    • 627 views
    • 
    • Added by Patient Safety Learning
    • 25 May

15. HSIB: Clinical investigation booking systems failures - written communications in community languages (April 2023)

    • Investigation
    • Health literacy
    • (and 8 more)

      Tagged with:

      • Investigation
      • Health literacy
      • Health inequalities
      • Appointment
      • Follow up
      • Patient
      • System safety
      • Tests / investigations
      • Communication problems
      • Patient death

    By Patient Safety Learning, 27 April

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

16. HSIB investigation: Non-accidental injuries in infants attending the emergency department (13 April 2023)

    • Children and Young People
    • Accident and Emergency
    • (and 10 more)

      Tagged with:

      • Children and Young People
      • Accident and Emergency
      • Baby
      • Safety process
      • Patient safety incident
      • Patient harmed
      • Investigation
      • Recommendations
      • Risk assessment
      • Social Care
      • Relative
      • Police

    By Patient Safety Learning, 13 April

    • 0 comments
    • 553 views
    • 
    • Added by Patient Safety Learning
    • 13 April

17. HSIB: Safety risk of air embolus associated with central venous catheters used for haemodialysis treatment (30 March 2023)

    • Investigation
    • Patient safety incident
    • (and 5 more)

      Tagged with:

      • Investigation
      • Patient safety incident
      • Patient harmed
      • Blood / blood products
      • Medical device
      • Skill-based issue
      • Training

    By Patient Safety Learning, 31 March

    • 0 comments
    • 311 views
    • 
    • Added by Patient Safety Learning
    • 31 March

18. HSIB: Care delivery within community mental health teams (23 March 2023)

    • Mental health
    • Investigation
    • (and 6 more)

      Tagged with:

      • Mental health
      • Investigation
      • Recommendations
      • Community care
      • Psychosis
      • Menopause
      • Risk assessment
      • Self harm/ suicide

    By Patient-Safety-Learning, 23 March

    • 0 comments
    • 413 views
    • 
    • Added by Patient-Safety-Learning
    • 23 March

19. HSIB national learning report: Assessment of risk during the maternity pathway (2 March 2023)

    • Maternity
    • Risk assessment
    • (and 7 more)

      Tagged with:

      • Maternity
      • Risk assessment
      • Labour
      • Pregnancy
      • Monitoring
      • High risk groups
      • Decision making
      • Communication
      • Consent

    By Patient-Safety-Learning, 2 March

    • 0 comments
    • 395 views
    • 
    • Added by Patient-Safety-Learning
    • 2 March

20. HSIB interim bulletin: Impact of staff wellbeing on patient safety (27 February 2023)

    • Investigation
    • Patient factors
    • (and 5 more)

      Tagged with:

      • Investigation
      • Patient factors
      • Patient harmed
      • Staff factors
      • Staff support
      • Emergency medicine
      • Ambulance

    By Patient Safety Learning, 27 February

    • 0 comments
    • 896 views
    • 
    • Added by Patient Safety Learning
    • 27 February

21. HSIB investigation: Access to critical patient information at the bedside (2 February 2023)

    • Investigation
    • Information sharing
    • (and 5 more)

      Tagged with:

      • Investigation
      • Information sharing
      • Care record
      • Electronic Health Record
      • Accessibility
      • Emergency medicine
      • Patient death

    By Patient-Safety-Learning, 2 February

    • 0 comments
    • 686 views
    • 
    • Added by Patient-Safety-Learning
    • 2 February

22. 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, 26 January

    • 0 comments
    • 484 views
    • 
    • Added by Patient-Safety-Learning
    • 26 January

23. 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
    • 541 views
    • 
    • Added by Patient Safety Learning
    • 3 January

24. 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
    • 557 views
    • 
    • Added by Patient Safety Learning
    • 21 December, 2022

25. 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
    • 420 views
    • 
    • Added by Patient-Safety-Learning
    • 8 December, 2022