HSIB investigations

Articles in this category

1. 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

   • 0 comments
   • 306 views
   • 
   • Added by Patient-Safety-Learning
   • 29 September

2. 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

   • 0 comments
   • 1,080 views
   • 
   • Added by Patient-Safety-Learning
   • 6 September

3. 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

   • 0 comments
   • 166 views
   • 
   • Added by Patient Safety Learning
   • 16 August

4. 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

   • 0 comments
   • 196 views
   • 
   • Added by Patient Safety Learning
   • 5 August

5. 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

   • 0 comments
   • 226 views
   • 
   • Added by Patient Safety Learning
   • 7 July

6. 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

   • 0 comments
   • 305 views
   • 
   • Added by Patient-Safety-Learning
   • 23 June

7. 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

   • 0 comments
   • 309 views
   • 
   • Added by Patient-Safety-Learning
   • 16 June

8. 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

   • 0 comments
   • 300 views
   • 
   • Added by Patient-Safety-Learning
   • 26 May

9. 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
   • 215 views
   • 
   • Added by Patient-Safety-Learning
   • 28 April

10. 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
    • 390 views
    • 
    • Added by Patient Safety Learning
    • 7 April

11. 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
    • 320 views
    • 
    • Added by Patient-Safety-Learning
    • 24 March

12. 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
    • 355 views
    • 
    • Added by Patient-Safety-Learning
    • 17 March

13. 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
    • 261 views
    • 
    • Added by Patient-Safety-Learning
    • 3 March

14. 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
    • 371 views
    • 
    • Added by Patient-Safety-Learning
    • 24 February

15. 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
    • 495 views
    • 
    • Added by Mark Hughes
    • 17 February

16. 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
    • 674 views
    • 
    • Added by Patient Safety Learning
    • 4 February

17. 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
    • 363 views
    • 
    • Added by Patient-Safety-Learning
    • 3 February

18. 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
    • 716 views
    • 
    • Added by Patient Safety Learning
    • 21 January

19. 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
    • 778 views
    • 
    • Added by Patient Safety Learning
    • 9 December, 2021

20. 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
    • 459 views
    • 
    • Added by Patient Safety Learning
    • 25 November, 2021

21. 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
    • 476 views
    • 
    • Added by Patient Safety Learning
    • 18 November, 2021

22. 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
    • 572 views
    • 
    • Added by Mark Hughes
    • 28 October, 2021

23. 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
    • 686 views
    • 
    • Added by Patient Safety Learning
    • 20 October, 2021

24. 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
    • 197 views
    • 
    • Added by Patient Safety Learning
    • 18 October, 2021

25. 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
    • 443 views
    • 
    • Added by Patient-Safety-Learning
    • 14 October, 2021