HSSIB investigations

Articles in this category

1. HSIB Annual Review 2022/23 (1 August 2023)

   • Investigation
   • Recommendations

   By Mark Hughes, 3 August, 2023

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

2. HSIB: The selection and insertion of vascular grafts in haemodialysis patients (27 July 2023)

   • Investigation
   • Medical device
   • (and 9 more)

     Tagged with:

     • Investigation
     • Medical device
     • Packaging/ labelling/ signage
     • Surgery - Vascular
     • Human factors
     • Patient harmed
     • Safety culture
     • Standards
     • Checklists
     • Technology
     • System safety

   By Patient Safety Learning, 27 July, 2023

   • 0 comments
   • 621 views
   • 
   • Added by Patient Safety Learning
   • 27 July, 2023

3. HSIB: Variations in the delivery of palliative care services to adults (13 July 2023)

   • Investigation
   • Medicine - Palliative
   • (and 5 more)

     Tagged with:

     • Investigation
     • Medicine - Palliative
     • End of life care
     • Cancer
     • Organisation / service factors
     • Integrated Care System (ICS)
     • Adult

   By Patient Safety Learning, 13 July, 2023

   • 0 comments
   • 1,251 views
   • 
   • Added by Patient Safety Learning
   • 13 July, 2023

4. HSSIB: Invasive procedures for patients with sickle cell disease (22 June 2023)

   • Investigation
   • Sickle cell
   • (and 4 more)

     Tagged with:

     • Investigation
     • Sickle cell
     • Medicine - Haematology
     • Patient harmed
     • Information sharing
     • Surgery - General

   By Patient Safety Learning, 22 June, 2023

   • 0 comments
   • 915 views
   • 
   • Added by Patient Safety Learning
   • 22 June, 2023

5. HSIB: Management of sickle cell crisis (22 June 2023)

   • Sickle cell
   • Investigation
   • (and 3 more)

     Tagged with:

     • Sickle cell
     • Investigation
     • Training
     • Skills gap
     • Patient death

   By Patient Safety Learning, 22 June, 2023

   • 0 comments
   • 1,347 views
   • 
   • Added by Patient Safety Learning
   • 22 June, 2023

6. HSIB: Clinical investigation booking systems failures - written communications in community languages (April 2023)

   • Investigation
   • Health literacy
   • (and 8 more)

     Tagged with:

     • Investigation
     • Health literacy
     • Health inequalities
     • Appointment
     • Follow up
     • Patient
     • System safety
     • Tests / investigations
     • Communication problems
     • Patient death

   By Patient Safety Learning, 27 April, 2023

   • 0 comments
   • 1,034 views
   • 
   • Added by Patient Safety Learning
   • 27 April, 2023

7. HSIB investigation: Non-accidental injuries in infants attending the emergency department (13 April 2023)

   • Children and Young People
   • Accident and Emergency
   • (and 10 more)

     Tagged with:

     • Children and Young People
     • Accident and Emergency
     • Baby
     • Safety process
     • Patient safety incident
     • Patient harmed
     • Investigation
     • Recommendations
     • Risk assessment
     • Social Care
     • Relative
     • Police

   By Patient Safety Learning, 13 April, 2023

   • 0 comments
   • 1,123 views
   • 
   • Added by Patient Safety Learning
   • 13 April, 2023

8. HSIB: Safety risk of air embolus associated with central venous catheters used for haemodialysis treatment (30 March 2023)

   • Investigation
   • Patient safety incident
   • (and 5 more)

     Tagged with:

     • Investigation
     • Patient safety incident
     • Patient harmed
     • Blood / blood products
     • Medical device
     • Skill-based issue
     • Training

   By Patient Safety Learning, 31 March, 2023

   • 0 comments
   • 811 views
   • 
   • Added by Patient Safety Learning
   • 31 March, 2023

9. HSIB: Care delivery within community mental health teams (23 March 2023)

   • Mental health
   • Investigation
   • (and 6 more)

     Tagged with:

     • Mental health
     • Investigation
     • Recommendations
     • Community care
     • Psychosis
     • Menopause
     • Risk assessment
     • Self harm/ suicide

   By Patient-Safety-Learning, 23 March, 2023

   • 0 comments
   • 1,351 views
   • 
   • Added by Patient-Safety-Learning
   • 23 March, 2023

10. HSIB national learning report: Assessment of risk during the maternity pathway (2 March 2023)

    • Maternity
    • Risk assessment
    • (and 7 more)

      Tagged with:

      • Maternity
      • Risk assessment
      • Labour
      • Pregnancy
      • Monitoring
      • High risk groups
      • Decision making
      • Communication
      • Consent

    By Patient-Safety-Learning, 2 March, 2023

    • 0 comments
    • 1,148 views
    • 
    • Added by Patient-Safety-Learning
    • 2 March, 2023

11. HSIB investigation: Access to critical patient information at the bedside (2 February 2023)

    • Investigation
    • Information sharing
    • (and 5 more)

      Tagged with:

      • Investigation
      • Information sharing
      • Care record
      • Electronic Health Record
      • Accessibility
      • Emergency medicine
      • Patient death

    By Patient-Safety-Learning, 2 February, 2023

    • 0 comments
    • 1,504 views
    • 
    • Added by Patient-Safety-Learning
    • 2 February, 2023

12. HSIB: Detection of jaundice in newborn babies (26 January 2023)

    • Investigation
    • UK
    • (and 6 more)

      Tagged with:

      • Investigation
      • UK
      • Baby
      • Screening
      • Tests / investigations
      • Patient harmed
      • NICU/SCBU
      • Race

    By Patient-Safety-Learning, 26 January, 2023

    • 0 comments
    • 1,379 views
    • 
    • Added by Patient-Safety-Learning
    • 26 January, 2023

13. HSIB: Supporting NHS staff involved in patient safety investigations (19 December 2022)

    • Investigation
    • Staff support
    • (and 3 more)

      Tagged with:

      • Investigation
      • Staff support
      • Patient safety incident
      • Organisational learning
      • Psychological safety

    By Patient Safety Learning, 3 January, 2023

    • 0 comments
    • 929 views
    • 
    • Added by Patient Safety Learning
    • 3 January, 2023

14. HSIB: Safety investigation jargon buster

    • Investigation
    • Communication
    • (and 1 more)

      Tagged with:

      • Investigation
      • Communication
      • Patient safety incident

    By Patient Safety Learning, 21 December, 2022

    • 0 comments
    • 1,000 views
    • 
    • Added by Patient Safety Learning
    • 21 December, 2022

15. HSIB - The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period final report (8 December 2022)

    • Deep vein thrombosis
    • Pregnancy
    • (and 5 more)

      Tagged with:

      • Deep vein thrombosis
      • Pregnancy
      • Maternity
      • Post partum
      • Diagnosis
      • Medication
      • Patient harmed

    By Patient-Safety-Learning, 8 December, 2022

    • 0 comments
    • 1,346 views
    • 
    • Added by Patient-Safety-Learning
    • 8 December, 2022

16. Harmed Patient Safety Governance role: An open letter from a patient safety campaigner

    • Patient engagement
    • Patient / family involvement
    • (and 2 more)

      Tagged with:

      • Patient engagement
      • Patient / family involvement
      • Investigation
      • Patient harmed

    By richard vA, 30 November, 2022

    • 1 comment
    • 1,734 views
    • 
    • Comment by richard vA
    • 6 January, 2023

17. HSIB - Clinical investigation booking systems failures interim report (24 November 2022)

    • Appointment
    • Electronic Health Record
    • (and 6 more)

      Tagged with:

      • Appointment
      • Electronic Health Record
      • Imaging
      • Communication
      • Diagnosis
      • Diagnostic error
      • England
      • Cancer

    By Patient-Safety-Learning, 24 November, 2022

    • 0 comments
    • 890 views
    • 
    • Added by Patient-Safety-Learning
    • 24 November, 2022

18. HSIB interim bulletin - Harm caused by delays in transferring patients to the right place of care (3 November 2022)

    • Ambulance
    • Handover
    • (and 6 more)

      Tagged with:

      • Ambulance
      • Handover
      • Emergency medicine
      • Accident and Emergency
      • Deterioration
      • Patient harmed
      • Investigation
      • England

    By Patient-Safety-Learning, 3 November, 2022

    • 0 comments
    • 884 views
    • 
    • Added by Patient-Safety-Learning
    • 3 November, 2022

19. Healthcare Safety Investigations Conference 2022: presentations and videos (21 September 2022)

    • Investigation
    • System safety
    • (and 4 more)

      Tagged with:

      • Investigation
      • System safety
      • Maternity
      • Medication
      • Patient safety incident
      • Patient harmed

    By Patient Safety Learning, 28 October, 2022

    • 0 comments
    • 1,411 views
    • 
    • Added by Patient Safety Learning
    • 28 October, 2022

20. HSIB’s local investigation pilot: shared learning for local healthcare systems (13 October 2022)

    • Investigation
    • Innovation
    • (and 6 more)

      Tagged with:

      • Investigation
      • Innovation
      • Patient identification
      • Handover
      • Emergency medicine
      • Integrated Care System (ICS)
      • England
      • Organisational learning

    By Patient-Safety-Learning, 13 October, 2022

    • 0 comments
    • 889 views
    • 
    • Added by Patient-Safety-Learning
    • 13 October, 2022

21. 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, 2022

    • 0 comments
    • 2,671 views
    • 
    • Added by Patient-Safety-Learning
    • 29 September, 2022

22. 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, 2022

    • 0 comments
    • 3,721 views
    • 
    • Added by Patient-Safety-Learning
    • 6 September, 2022

23. 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, 2022

    • 0 comments
    • 1,875 views
    • 
    • Added by Patient Safety Learning
    • 16 August, 2022

24. 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, 2022

    • 0 comments
    • 1,044 views
    • 
    • Added by Patient Safety Learning
    • 5 August, 2022

25. 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, 2022

    • 0 comments
    • 1,350 views
    • 
    • Added by Patient Safety Learning
    • 7 July, 2022