HSIB investigations

Articles in this category

1. 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, Tuesday at 08:25

   • 0 comments
   • 42 views
   • 
   • Added by Patient Safety Learning
   • Tuesday at 08:25

2. 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
   • 73 views
   • 
   • Added by Patient Safety Learning
   • 15 March

3. 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
   • 144 views
   • 
   • Added by Patient Safety Learning
   • 4 March

4. 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
   • 229 views
   • 
   • Added by Patient Safety Learning
   • 25 February

5. 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
   • 165 views
   • 
   • Added by Patient Safety Learning
   • 4 February

6. 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
   • 158 views
   • 
   • Added by Patient Safety Learning
   • 28 January

7. 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
   • 468 views
   • 
   • Added by PatientSafetyLearning Team
   • 21 January

8. 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
   • 279 views
   • 
   • Added by Patient Safety Learning
   • 17 December, 2020

9. 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
   • 259 views
   • 
   • Added by Patient Safety Learning
   • 3 December, 2020

10. 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
    • 273 views
    • 
    • Added by Patient Safety Learning
    • 12 November, 2020

11. 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
    • 76 views
    • 
    • Added by PatientSafetyLearning Team
    • 9 November, 2020

12. 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
    • 262 views
    • 
    • Added by Patient Safety Learning
    • 29 October, 2020

13. HSIB: Summary report. Unplanned delayed removal of ureteric stents (October 2020)

    • Investigation
    • Recommendations
    • (and 1 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Surgery - Urology

    By Patient Safety Learning, 22 October, 2020

    • 0 comments
    • 131 views
    • 
    • Added by Patient Safety Learning
    • 22 October, 2020

14. HSIB: Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke (13 October 2020)

    • Investigation
    • Recommendations
    • (and 3 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Stroke
      • Treatment
      • Patient harmed

    By Patient Safety Learning, 13 October, 2020

    • 0 comments
    • 173 views
    • 
    • Added by Patient Safety Learning
    • 13 October, 2020

15. HSIB: The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital (24 September 2020)

    • Adminstering medication
    • Investigation
    • (and 3 more)

      Tagged with:

      • Adminstering medication
      • Investigation
      • Patient death
      • Medicine - Clinical pharmacology
      • Older People (over 65)

    By Patient Safety Learning, 24 September, 2020

    • 0 comments
    • 489 views
    • 
    • Added by Patient Safety Learning
    • 24 September, 2020

16. National Learning Report. Giving families a voice: HSIB’s approach to patient and family engagement during investigations (17 September 2020)

    • Investigation
    • Patient / family involvement
    • (and 3 more)

      Tagged with:

      • Investigation
      • Patient / family involvement
      • Patient engagement
      • Feedback
      • Patient safety incident

    By Patient Safety Learning, 17 September, 2020

    • 0 comments
    • 202 views
    • 
    • Added by Patient Safety Learning
    • 17 September, 2020

17. HSIB National Intelligence Report. Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response (August 2020)

    • Virus
    • Infection control
    • (and 5 more)

      Tagged with:

      • Virus
      • Infection control
      • PPE (personal Protective Equipment)
      • Investigation
      • Recommendations
      • Care home
      • Patient death

    By Patient Safety Learning, 27 August, 2020

    • 0 comments
    • 505 views
    • 
    • Added by Patient Safety Learning
    • 27 August, 2020

18. Healthcare Safety Investigation Branch Annual Review 2019/20

    • Investigation
    • Recommendations
    • (and 1 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Patient safety incident

    By Sam, 15 August, 2020

    • 0 comments
    • 177 views
    • 
    • Added by Sam
    • 15 August, 2020

19. 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, 16 July, 2020

    • 0 comments
    • 508 views
    • 
    • Added by PatientSafetyLearning Team
    • 16 July, 2020

20. 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, 8 April, 2020

    • 0 comments
    • 313 views
    • 
    • Added by Patient Safety Learning
    • 8 April, 2020

21. 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, 26 March, 2020

    • 0 comments
    • 275 views
    • 
    • Added by PatientSafetyLearning Team
    • 26 March, 2020

22. 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, 19 March, 2020

    • 0 comments
    • 288 views
    • 
    • Added by Patient Safety Learning
    • 19 March, 2020

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

    • Pregnancy
    • Investigation
    • (and 1 more)

      Tagged with:

      • Pregnancy
      • Investigation
      • Diagnosis

    By Patient Safety Learning, 5 March, 2020

    • 0 comments
    • 317 views
    • 
    • Added by Patient Safety Learning
    • 5 March, 2020

24. 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, 24 February, 2020

    • 0 comments
    • 233 views
    • 
    • Added by Claire Cox
    • 24 February, 2020

25. 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, 6 February, 2020

    • 0 comments
    • 433 views
    • 
    • Added by Sam
    • 6 February, 2020