HSSIB investigations

Articles in this category

1. HSSIB interim report. Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning (12 September 2024)

   • Patient death
   • Near miss
   • (and 9 more)

     Tagged with:

     • Patient death
     • Near miss
     • Self harm/ suicide
     • Investigation
     • Mental health
     • Community care
     • Risk assessment
     • Risk management
     • Assessment
     • Person-centred care
     • Staff engagement

   By Patient Safety Learning, 12 September, 2024

   • 0 comments
   • 973 views
   • 
   • Added by Patient Safety Learning
   • 12 September, 2024

2. HSSIB investigation report. Workforce and patient safety: temporary staff – integration into healthcare providers (5 September 2024)

   • Staff factors
   • Recruitment
   • (and 1 more)

     Tagged with:

     • Staff factors
     • Recruitment
     • Workforce management

   By Mark Hughes, 5 September, 2024

   • 0 comments
   • 775 views
   • 
   • Added by Mark Hughes
   • 5 September, 2024

3. HSSIB investigation report – Healthcare provision in prisons: emergency care response (29 August 2024)

   • Prison
   • Ambulance
   • (and 1 more)

     Tagged with:

     • Prison
     • Ambulance
     • Investigation

   By Mark Hughes, 29 August, 2024

   • 0 comments
   • 727 views
   • 
   • Added by Mark Hughes
   • 29 August, 2024

4. HSSIB investigation report - Workforce and patient safety: digital tools for online consultation in general practice (25 July 2024)

   • GP
   • Primary care
   • (and 2 more)

     Tagged with:

     • GP
     • Primary care
     • Consultation
     • Digital health

   By Mark Hughes, 25 July, 2024

   • 0 comments
   • 1,855 views
   • 
   • Added by Mark Hughes
   • 25 July, 2024

5. Health Services Safety Investigations Body Annual Report and Accounts 2023/24 (17 July 2024)

   • Investigation
   • Organisational learning
   • (and 1 more)

     Tagged with:

     • Investigation
     • Organisational learning
     • Quality improvement

   By Patient-Safety-Learning, 24 July, 2024

   • 0 comments
   • 502 views
   • 
   • Added by Patient-Safety-Learning
   • 24 July, 2024

6. HSSIB investigation report – Keeping children and young people with mental health needs safe: the design of the paediatric ward (23 May 2024)

   • Patient harmed
   • Mental health
   • (and 2 more)

     Tagged with:

     • Patient harmed
     • Mental health
     • Paediatrics
     • Children and Young People

   By Mark Hughes, 23 May, 2024

   • 0 comments
   • 952 views
   • 
   • Added by Mark Hughes
   • 23 May, 2024

7. HSSIB investigation report – Patients at risk of self-harm: continuous observation (9 May 2024)

   • Mental health
   • Patient harmed
   • (and 2 more)

     Tagged with:

     • Mental health
     • Patient harmed
     • Self harm/ suicide
     • Observations

   By Mark Hughes, 9 May, 2024

   • 0 comments
   • 830 views
   • 
   • Added by Mark Hughes
   • 9 May, 2024

8. Tackling health inequity: observations from an investigation visit (HSSIB, 30 April 2024)

   • Health inequalities
   • Health Disparities

   By Mark Hughes, 2 May, 2024

   • 0 comments
   • 608 views
   • 
   • Added by Mark Hughes
   • 2 May, 2024

9. Public consultation: HSSIB strategy and investigation criteria (16 April 2024)

   • Feedback
   • Patient engagement
   • (and 1 more)

     Tagged with:

     • Feedback
     • Patient engagement
     • Patient safety strategy

   By Patient-Safety-Learning, 18 April, 2024

   • 0 comments
   • 640 views
   • 
   • Added by Patient-Safety-Learning
   • 18 April, 2024

10. HSSIB investigation report: Retained swabs following invasive procedures (16 April 2024)

    • Surgery - General
    • User centred design
    • (and 5 more)

      Tagged with:

      • Surgery - General
      • User centred design
      • Never event
      • Surgeon
      • Investigation
      • Human factors
      • Technology

    By Patient Safety Learning, 16 April, 2024

    • 0 comments
    • 1,388 views
    • 
    • Added by Patient Safety Learning
    • 16 April, 2024

11. HSSIB investigation report: Temporary staff – involvement in patient safety investigations (14 March 2024)

    • Investigation
    • Workforce management
    • (and 5 more)

      Tagged with:

      • Investigation
      • Workforce management
      • Patient safety incident
      • Staff factors
      • Staff engagement
      • Organisational learning
      • PSIRF

    By Patient Safety Learning, 14 March, 2024

    • 0 comments
    • 998 views
    • 
    • Added by Patient Safety Learning
    • 14 March, 2024

12. Elective care recovery: taking a systems approach (HSSIB, 5 March 2024)

    • Organisation / service factors
    • Treatment
    • (and 6 more)

      Tagged with:

      • Organisation / service factors
      • Treatment
      • Screening
      • Surgery - General
      • Long waiting list
      • Investigation
      • Communication
      • Lack of resources

    By Patient Safety Learning, 5 March, 2024

    • 0 comments
    • 738 views
    • 
    • Added by Patient Safety Learning
    • 5 March, 2024

13. Doctor, Doctor podcast with Dr Rosie Benneyworth (BBC Sounds, 5 December 2023)

    • Investigation
    • Leadership

    By Patient Safety Learning, 12 February, 2024

    • 0 comments
    • 594 views
    • 
    • Added by Patient Safety Learning
    • 12 February, 2024

14. HSSIB National learning report: Positive patient identification (8 February 2024)

    • Investigation
    • Organisational learning
    • (and 2 more)

      Tagged with:

      • Investigation
      • Organisational learning
      • Recommendations
      • Patient identification

    By Patient Safety Learning, 8 February, 2024

    • 0 comments
    • 1,147 views
    • 
    • Added by Patient Safety Learning
    • 8 February, 2024

15. Policy paper: Framework agreement between DHSC and the Health Services Safety Investigations Body (HSSIB) (25 January 2024)

    • Investigation
    • Accountability
    • (and 1 more)

      Tagged with:

      • Investigation
      • Accountability
      • Organisation / service factors

    By Patient Safety Learning, 30 January, 2024

    • 0 comments
    • 504 views
    • 
    • Added by Patient Safety Learning
    • 30 January, 2024

16. HSSIB: Advanced airway management in patients with a known complex disease (25 January 2024)

    • Medicine - Respiratory
    • Investigation
    • (and 2 more)

      Tagged with:

      • Medicine - Respiratory
      • Investigation
      • Patient death
      • Information sharing

    By Patient Safety Learning, 25 January, 2024

    • 0 comments
    • 1,302 views
    • 
    • Added by Patient Safety Learning
    • 25 January, 2024

17. Electronic patient record systems: recurring themes arising from safety investigations (HSSIB, 19 December 2023)

    • Investigation
    • Recommendations
    • (and 3 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Electronic Health Record
      • Data
      • Patient harmed

    By Patient Safety Learning, 20 December, 2023

    • 0 comments
    • 1,078 views
    • 
    • Added by Patient Safety Learning
    • 20 December, 2023

18. 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, 7 December, 2023

    • 0 comments
    • 1,002 views
    • 
    • Added by Patient Safety Learning
    • 7 December, 2023

19. 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, 2023

    • 0 comments
    • 954 views
    • 
    • Added by Patient Safety Learning
    • 30 November, 2023

20. 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, 2023

    • 0 comments
    • 977 views
    • 
    • Added by Patient Safety Learning
    • 16 November, 2023

21. 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, 2023

    • 0 comments
    • 1,317 views
    • 
    • Added by Patient Safety Learning
    • 2 November, 2023

22. 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, 2023

    • 0 comments
    • 1,623 views
    • 
    • Added by Patient Safety Learning
    • 2 November, 2023

23. 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, 2023

    • 0 comments
    • 2,109 views
    • 
    • Added by Patient Safety Learning
    • 18 October, 2023

24. 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, 2023

    • 0 comments
    • 2,162 views
    • 
    • Added by Patient-Safety-Learning
    • 24 August, 2023

25. 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, 2023

    • 0 comments
    • 779 views
    • 
    • Added by Mark Hughes
    • 3 August, 2023