HSIB investigations

Articles in this category

1. 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
   • 138 views
   • 
   • Added by Patient-Safety-Learning
   • 16 July

2. 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
   • 214 views
   • 
   • Added by Patient Safety Learning
   • 3 June

3. 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
   • 113 views
   • 
   • Added by Patient Safety Learning
   • 24 May

4. A thematic analysis of HSIB's first 22 national investigations (May 2021)

   • Investigation
   • Patient safety incident

   By Patient Safety Learning, 20 May

   • 0 comments
   • 186 views
   • 
   • Added by Patient Safety Learning
   • 20 May

5. 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
   • 78 views
   • 
   • Added by PatientSafetyLearning Team
   • 12 May

6. 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
   • 178 views
   • 
   • Added by Patient Safety Learning
   • 5 May

7. 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
   • 130 views
   • 
   • Added by Patient Safety Learning
   • 30 April

8. 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
   • 171 views
   • 
   • Added by Patient Safety Learning
   • 27 April

9. 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
   • 149 views
   • 
   • Added by Patient Safety Learning
   • 20 April

10. 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
    • 125 views
    • 
    • Added by Patient Safety Learning
    • 15 March

11. 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
    • 212 views
    • 
    • Added by Patient Safety Learning
    • 4 March

12. 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
    • 347 views
    • 
    • Added by Patient Safety Learning
    • 25 February

13. 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
    • 221 views
    • 
    • Added by Patient Safety Learning
    • 4 February

14. 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
    • 218 views
    • 
    • Added by Patient Safety Learning
    • 28 January

15. 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
    • 574 views
    • 
    • Added by PatientSafetyLearning Team
    • 21 January

16. 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
    • 338 views
    • 
    • Added by Patient Safety Learning
    • 17 December, 2020

17. 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
    • 320 views
    • 
    • Added by Patient Safety Learning
    • 3 December, 2020

18. 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
    • 322 views
    • 
    • Added by Patient Safety Learning
    • 12 November, 2020

19. 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
    • 110 views
    • 
    • Added by PatientSafetyLearning Team
    • 9 November, 2020

20. 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
    • 308 views
    • 
    • Added by Patient Safety Learning
    • 29 October, 2020

21. 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
    • 172 views
    • 
    • Added by Patient Safety Learning
    • 22 October, 2020

22. 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
    • 215 views
    • 
    • Added by Patient Safety Learning
    • 13 October, 2020

23. 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
    • 589 views
    • 
    • Added by Patient Safety Learning
    • 24 September, 2020

24. 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
    • 252 views
    • 
    • Added by Patient Safety Learning
    • 17 September, 2020

25. 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
    • 602 views
    • 
    • Added by Patient Safety Learning
    • 27 August, 2020