HSSIB investigations

Articles in this category

1. HSSIB investigation report: Workforce and patient safety: electronic communications on patient discharge from acute hospitals (10 July 2025)

   • Discharge
   • Communication problems
   • (and 5 more)

     Tagged with:

     • Discharge
     • Communication problems
     • Investigation
     • Digital health
     • Patient harmed
     • Electronic Patient Record
     • Clinical administration

   By Patient Safety Learning, 10 July, 2025

   • 0 comments
   • 1,112 views
   • 
   • Added by Patient Safety Learning
   • 10 July, 2025

2. Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF) (HSSIB, 26 June 2025)

   • Investigation
   • Sepsis
   • (and 5 more)

     Tagged with:

     • Investigation
     • Sepsis
     • PSIRF
     • Diagnosis
     • Deterioration
     • Diabetes
     • Ulcers / pressure sores

   By Patient Safety Learning, 26 June, 2025

   • 1 comment
   • 795 views
   • 
   • Comment by Anonymous
   • 16 October, 2025

3. HSSIB investigation report: Mental health inpatient settings: overarching report of investigations directed by the Secretary of State for Health and Social Care (13 May 2025)

   • Mental health
   • Mental health unit
   • (and 8 more)

     Tagged with:

     • Mental health
     • Mental health unit
     • Self harm/ suicide
     • Transfer of care
     • Risk assessment
     • Risk management
     • Person-centred care
     • Culture of fear
     • Safe staffing
     • Digital health

   By Mark Hughes, 13 May, 2025

   • 0 comments
   • 1,469 views
   • 
   • Added by Mark Hughes
   • 13 May, 2025

4. HSSIB Investigation report: The impact of staff fatigue on patient safety (24 April 2025)

   • Fatigue / exhaustion
   • Staff safety
   • (and 5 more)

     Tagged with:

     • Fatigue / exhaustion
     • Staff safety
     • Patient harmed
     • Investigation
     • Staff support
     • System safety
     • Working hours

   By Patient Safety Learning, 24 April, 2025

   • 1 comment
   • 3,488 views
   • 
   • Comment by Elaine Freeman
   • 28 February

5. Care co-ordination for people with long-term conditions: Patient Safety Learning’s response to HSSIB investigation

   • Care coordination
   • Care navigation
   • (and 9 more)

     Tagged with:

     • Care coordination
     • Care navigation
     • Carer
     • Patient
     • Patient / family involvement
     • Community care
     • Social Care
     • Healthcare
     • Communication
     • Information sharing
     • Electronic Patient Record

   By Patient Safety Learning, 10 April, 2025

   • 0 comments
   • 956 views
   • 
   • Added by Patient Safety Learning
   • 10 April, 2025

6. HSSIB Investigation Report: Workforce and patient safety - primary and community care co-ordination for people with long-term conditions (10 April 2025)

   • Investigation
   • Healthcare
   • (and 10 more)

     Tagged with:

     • Investigation
     • Healthcare
     • Social Care
     • Care coordination
     • Care navigation
     • Communication
     • Long-term conditions
     • Information sharing
     • Patient
     • Community care
     • Carer
     • Patient / family involvement

   By Patient Safety Learning, 10 April, 2025

   • 0 comments
   • 810 views
   • 
   • Added by Patient Safety Learning
   • 10 April, 2025

7. HSSIB investigation: 12-lead electrocardiograms (ECGs) in ambulance services: paramedic education, training and competence (27 March 2025)

   • Ambulance
   • Paramedic
   • (and 6 more)

     Tagged with:

     • Ambulance
     • Paramedic
     • Patient death
     • Investigation
     • Medicine - Cardiology
     • Training
     • Skill-based issue
     • Students

   By Patient Safety Learning, 27 March, 2025

   • 0 comments
   • 756 views
   • 
   • Added by Patient Safety Learning
   • 27 March, 2025

8. HSSIB investigation report: Medication not given: anticoagulation before and after a procedure (13 March 2025)

   • Medication
   • Investigation
   • (and 5 more)

     Tagged with:

     • Medication
     • Investigation
     • Electronic Health Record
     • Stroke
     • Surgery - General
     • Patient death
     • Older People (over 65)

   By Patient-Safety-Learning, 13 March, 2025

   • 0 comments
   • 761 views
   • 
   • Added by Patient-Safety-Learning
   • 13 March, 2025

9. Patient safety in Japan: no-fault compensation for birth injury (HSSIB, 3 March 2025)

   • Investigation
   • Japan
   • (and 4 more)

     Tagged with:

     • Investigation
     • Japan
     • Complaint
     • Patient / family involvement
     • Patient harmed
     • Baby

   By Patient Safety Learning, 4 March, 2025

   • 0 comments
   • 406 views
   • 
   • Added by Patient Safety Learning
   • 4 March, 2025

10. Patient safety in Japan: national reporting and learning system (HSSIB, 20 February 2025)

    By Patient Safety Learning, 20 February, 2025

    • 0 comments
    • 450 views
    • 
    • Added by Patient Safety Learning
    • 20 February, 2025

11. HSSIB investigation report: Safety management: accountability across organisational boundaries (13 February 2025)

    • Investigation
    • System safety
    • (and 9 more)

      Tagged with:

      • Investigation
      • System safety
      • Safety management
      • Risk management
      • Recommendations
      • LFPSE
      • Patient engagement
      • Patient safety incident
      • Integrated Care System (ICS)
      • Care coordination
      • Integrated Care Board (ICB)

    By Patient Safety Learning, 13 February, 2025

    • 0 comments
    • 1,070 views
    • 
    • Added by Patient Safety Learning
    • 13 February, 2025

12. HSSIB investigation report - Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge (30 January 2025)

    • Mental health unit
    • Mental health
    • (and 4 more)

      Tagged with:

      • Mental health unit
      • Mental health
      • Patient death
      • Organisational learning
      • Investigation
      • Self harm/ suicide

    By Patient-Safety-Learning, 30 January, 2025

    • 0 comments
    • 2,152 views
    • 
    • Added by Patient-Safety-Learning
    • 30 January, 2025

13. Consolidating safety investigation: Finland’s journey and the influence of the HSSIB (19 December 2024)

    • Investigation
    • Organisation / service factors
    • (and 1 more)

      Tagged with:

      • Investigation
      • Organisation / service factors
      • Europe

    By Patient Safety Learning, 23 December, 2024

    • 0 comments
    • 504 views
    • 
    • Added by Patient Safety Learning
    • 23 December, 2024

14. HSSIB's investigation criteria (18 December 2024)

    • Investigation
    • Patient safety incident
    • (and 3 more)

      Tagged with:

      • Investigation
      • Patient safety incident
      • Transparency
      • Patient / family involvement
      • Collaboration

    By Patient Safety Learning, 19 December, 2024

    • 0 comments
    • 601 views
    • 
    • Added by Patient Safety Learning
    • 19 December, 2024

15. HSSIB: Strategy and Investigation Criteria (18 December 2024)

    • Investigation
    • Patient safety strategy
    • (and 3 more)

      Tagged with:

      • Investigation
      • Patient safety strategy
      • Organisational learning
      • Health education
      • Collaboration

    By Patient Safety Learning, 19 December, 2024

    • 0 comments
    • 531 views
    • 
    • Added by Patient Safety Learning
    • 19 December, 2024

16. Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (HSSIB, 12 December 2024)

    • Investigation
    • Mental health
    • (and 4 more)

      Tagged with:

      • Investigation
      • Mental health
      • Patient harmed
      • Children and Young People
      • Self harm/ suicide
      • Patient death

    By Mark Hughes, 12 December, 2024

    • 0 comments
    • 897 views
    • 
    • Added by Mark Hughes
    • 12 December, 2024

17. HSSIB investigation report: Medication not given: administration of time critical medication in the emergency department (5 December 2024)

    • Emergency medicine
    • Parkinsons disease
    • (and 6 more)

      Tagged with:

      • Emergency medicine
      • Parkinsons disease
      • Medication
      • Adminstering medication
      • Care coordination
      • Communication
      • Decision making
      • Investigation

    By Patient Safety Learning, 5 December, 2024

    • 0 comments
    • 1,730 views
    • 
    • Added by Patient Safety Learning
    • 5 December, 2024

18. How HSSIB contributes to patient safety: a view from Sweden (3 December 2024)

    • Investigation
    • Sweden
    • (and 2 more)

      Tagged with:

      • Investigation
      • Sweden
      • Patient safety incident
      • Organisational learning

    By Patient Safety Learning, 3 December, 2024

    • 0 comments
    • 469 views
    • 
    • Added by Patient Safety Learning
    • 3 December, 2024

19. HSSIB investigation report – Healthcare provision in prisons: continuity of care (28 November 2024)

    • Prison
    • Primary care
    • (and 2 more)

      Tagged with:

      • Prison
      • Primary care
      • Appointment
      • Transfer of care

    By Mark Hughes, 28 November, 2024

    • 0 comments
    • 1,054 views
    • 
    • Added by Mark Hughes
    • 28 November, 2024

20. Mental health inpatient settings: out of area placements (HSSIB, 21 November 2024)

    • Investigation
    • Mental health
    • (and 6 more)

      Tagged with:

      • Investigation
      • Mental health
      • Self harm/ suicide
      • Patient harmed
      • Discharge
      • Care coordination
      • Patient / family involvement
      • Lack of resources

    By Patient Safety Learning, 21 November, 2024

    • 0 comments
    • 702 views
    • 
    • Added by Patient Safety Learning
    • 21 November, 2024

21. How HSSIB contributes to patient safety: a view from Australia (4 November 2024)

    • Australia
    • Investigation
    • (and 2 more)

      Tagged with:

      • Australia
      • Investigation
      • Health education
      • Quality improvement

    By Patient Safety Learning, 7 November, 2024

    • 0 comments
    • 520 views
    • 
    • Added by Patient Safety Learning
    • 7 November, 2024

22. HSSIB investigation report – Sexual safety: the implications for patient safety (31 October 2024)

    • Staff safety
    • Behaviour
    • (and 2 more)

      Tagged with:

      • Staff safety
      • Behaviour
      • Investigation
      • Violence

    By Mark Hughes, 31 October, 2024

    • 0 comments
    • 618 views
    • 
    • Added by Mark Hughes
    • 31 October, 2024

23. HSSIB investigation report - Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings (24 October 2024)

    • Mental health
    • Mental health - adult
    • (and 5 more)

      Tagged with:

      • Mental health
      • Mental health - adult
      • Physical environment
      • Staff factors
      • Restrictive practice
      • Workforce management
      • Organisational culture

    By Patient-Safety-Learning, 24 October, 2024

    • 0 comments
    • 1,104 views
    • 
    • Added by Patient-Safety-Learning
    • 24 October, 2024

24. The investigator’s toolkit: FRAM (9 October 2024)

    • Investigation
    • Task analysis
    • (and 3 more)

      Tagged with:

      • Investigation
      • Task analysis
      • protocols and procedures
      • Patient safety incident
      • System safety

    By Patient Safety Learning, 10 October, 2024

    • 0 comments
    • 541 views
    • 
    • Added by Patient Safety Learning
    • 10 October, 2024

25. HSSIB Report – Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare (16 September 2024)

    • Leadership
    • Recommendations
    • (and 1 more)

      Tagged with:

      • Leadership
      • Recommendations
      • Implementation

    By Mark Hughes, 16 September, 2024

    • 0 comments
    • 827 views
    • 
    • Added by Mark Hughes
    • 16 September, 2024