HSSIB investigations

Articles in this category

1. HSIB report: Undiagnosed cardiomyopathy in a young person with autism (19 March 2020)

   • Anaesthesia
   • Imaging
   • (and 3 more)

     Tagged with:

     • Anaesthesia
     • Imaging
     • Learning disorders
     • Autism
     • Investigation

   By Patient Safety Learning, 19 March, 2020

   • 0 comments
   • 1,243 views
   • 
   • Added by Patient Safety Learning
   • 19 March, 2020

2. HSIB report: The diagnosis of ectopic pregnancy (5 March 2020)

   • Pregnancy
   • Investigation
   • (and 1 more)

     Tagged with:

     • Pregnancy
     • Investigation
     • Diagnosis

   By Patient Safety Learning, 5 March, 2020

   • 0 comments
   • 1,864 views
   • 
   • Added by Patient Safety Learning
   • 5 March, 2020

3. HSIB report: Implantation of wrong prostheses during joint replacement surgery (June 2018)

   • Never event
   • Investigation
   • (and 3 more)

     Tagged with:

     • Never event
     • Investigation
     • Human error
     • Latent error
     • Surgery - Trauma and orthopaedic

   By Claire Cox, 24 February, 2020

   • 0 comments
   • 1,122 views
   • 
   • Added by Claire Cox
   • 24 February, 2020

4. HSIB report: Investigation into potential under-recognised risk of harm from the use of propranolol (6 February 2020)

   • Prescribing
   • Patient death
   • (and 3 more)

     Tagged with:

     • Prescribing
     • Patient death
     • Medication
     • Investigation
     • Recommendations

   By Sam, 6 February, 2020

   • 0 comments
   • 2,635 views
   • 
   • Added by Sam
   • 6 February, 2020

5. HSIB: Investigation into delayed recognition of acute aortic dissection (23 January 2020)

   • Accident and Emergency
   • Patient death
   • (and 5 more)

     Tagged with:

     • Accident and Emergency
     • Patient death
     • Perception / understanding
     • Investigation
     • Recommendations
     • Emergency medicine
     • Medicine - Cardiology

   By Patient Safety Learning, 23 January, 2020

   • 0 comments
   • 1,673 views
   • 
   • Added by Patient Safety Learning
   • 23 January, 2020

6. HSIB report: Recognising and responding to critically unwell patients (May 2019)

   • Deterioration
   • Observations
   • (and 5 more)

     Tagged with:

     • Deterioration
     • Observations
     • Monitoring
     • Emergency medicine
     • Accident and Emergency
     • Recommendations
     • Human error

   By PatientSafetyLearning Team, 14 January, 2020

   • 0 comments
   • 1,410 views
   • 
   • Added by PatientSafetyLearning Team
   • 14 January, 2020

7. HSIB report: Lack of timely monitoring of patients with glaucoma (9 January 2020)

   • Patient
   • Follow up
   • (and 4 more)

     Tagged with:

     • Patient
     • Follow up
     • Medicine - Ophthalmology
     • Patient harmed
     • Investigation
     • Long waiting list

   By Patient Safety Learning, 9 January, 2020

   • 1 comment
   • 2,587 views
   • 
   • Comment by Patient Safety Learning
   • 9 January, 2020

8. Healthcare Safety Investigation Branch: Annual Review 2018/19

   • Information sharing
   • Personal reflection
   • (and 3 more)

     Tagged with:

     • Information sharing
     • Personal reflection
     • Evaluation
     • Policies / Protocols / Procedures
     • Investigation

   By Claire Cox, 20 December, 2019

   • 0 comments
   • 1,256 views
   • 
   • Added by Claire Cox
   • 20 December, 2019

9. HSIB report: Investigation into detection of retained vaginal swabs and tampons following childbirth (updated 15 July 2020)

   • Never event
   • Investigation
   • (and 2 more)

     Tagged with:

     • Never event
     • Investigation
     • Recommendations
     • Post partum

   By Patient Safety Learning, 19 December, 2019

   • 0 comments
   • 2,190 views
   • 
   • Added by Patient Safety Learning
   • 19 December, 2019

10. HSIB report: Investigation into electronic prescribing and medicines administration systems and safe discharge (October 2019)

    • Prescribing
    • Medicine - Clinical pharmacology
    • (and 2 more)

      Tagged with:

      • Prescribing
      • Medicine - Clinical pharmacology
      • Patient death
      • Adminstering medication

    By PatientSafetyLearning Team, 20 November, 2019

    • 0 comments
    • 1,809 views
    • 
    • Added by PatientSafetyLearning Team
    • 20 November, 2019

11. HSIB presentation at the Patient Safety Strategy Discussion Forum (18 November 2019)

    • Patient safety incident
    • Investigation
    • (and 1 more)

      Tagged with:

      • Patient safety incident
      • Investigation
      • Methodology

    By Patient Safety Learning, 18 November, 2019

    • 0 comments
    • 1,041 views
    • 
    • Added by Patient Safety Learning
    • 18 November, 2019

12. HSIB report: Electronic prescribing and medicines administration systems and safe discharge (24 October 2019)

    • Prescribing
    • Investigation
    • (and 4 more)

      Tagged with:

      • Prescribing
      • Investigation
      • Pharmacist
      • Transfer of care
      • Medication
      • Digital health

    By Patient Safety Learning, 24 October, 2019

    • 0 comments
    • 2,055 views
    • 
    • Added by Patient Safety Learning
    • 24 October, 2019

13. HSIB report: Investigation into management of chronic health conditions in prisons (10 October 2019)

    • Prison
    • Prison warden
    • (and 4 more)

      Tagged with:

      • Prison
      • Prison warden
      • Patient
      • Transfer of care
      • Treatment
      • Medication

    By Patient Safety Learning, 14 October, 2019

    • 0 comments
    • 1,406 views
    • 
    • Added by Patient Safety Learning
    • 14 October, 2019

14. HSIB report: Investigation into wrong patient details on blood sample (26 September 2019)

    • Near miss
    • Blood / blood products
    • (and 4 more)

      Tagged with:

      • Near miss
      • Blood / blood products
      • Orders / requests
      • Human error
      • Fatigue / exhaustion
      • Investigation

    By Patient Safety Learning, 26 September, 2019

    • 0 comments
    • 1,427 views
    • 
    • Added by Patient Safety Learning
    • 26 September, 2019

15. HSIB report: Management of acute onset testicular pain (12 September 2019)

    By Claire Cox, 12 September, 2019

    • 0 comments
    • 1,625 views
    • 
    • Added by Claire Cox
    • 12 September, 2019

16. HSIB report: Investigation into failures in communication or follow-up of unexpected significant radiological findings (July 2019)

    • Radiologist
    • Diagnosis
    • (and 5 more)

      Tagged with:

      • Radiologist
      • Diagnosis
      • Medicine - Oncology
      • Patient death
      • Communication problems
      • Cancer
      • Investigation

    By Patient Safety Learning, 19 July, 2019

    • 0 comments
    • 1,782 views
    • 
    • Added by Patient Safety Learning
    • 19 July, 2019

17. HSIB report: Inadvertent administration of an oral liquid medicine into a vein (April 2019)

    • Medication
    • Prescribing
    • (and 9 more)

      Tagged with:

      • Medication
      • Prescribing
      • Doctor
      • Nurse
      • Patient
      • Near miss
      • Human error
      • System safety
      • Process redesign
      • Investigation
      • Risk management

    By Patient Safety Learning, 26 June, 2019

    • 1 comment
    • 2,039 views
    • 
    • Comment by Derek Malyon
    • 1 February, 2021

18. HSIB report: Insertion of an incorrect intraocular lens (update November 2018)

    • Medicine - Ophthalmology
    • Medical device / equipment
    • (and 5 more)

      Tagged with:

      • Medicine - Ophthalmology
      • Medical device / equipment
      • Readmission
      • Safety assessment
      • Investigation
      • Recommendations
      • Near miss

    By Patient Safety Learning, 26 June, 2019

    • 0 comments
    • 1,097 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019

19. HSIB report: Investigation into the design and safe use of portable oxygen systems (November 2018)

    • Investigation
    • Risk management
    • (and 5 more)

      Tagged with:

      • Investigation
      • Risk management
      • Recommendations
      • Medicine - Respiratory
      • Emergency medicine
      • Oxygen / gas / vapour
      • Violence/ abuse

    By Patient Safety Learning, 26 June, 2019

    • 0 comments
    • 3,132 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019

20. HSIB report: Transfer of the critically ill adult (24 January 2019)

    • Investigation
    • Recommendations
    • (and 4 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Risk management
      • Medicine - Cardiology
      • Paramedic
      • Adult

    By Patient Safety Learning, 26 June, 2019

    • 0 comments
    • 1,320 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019