Patient safety investigations

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Aerial view of a prison site in the English countryside.

Healthcare provision in prisons

published
We've analysed the patient safety issues frequently highlighted within prison healthcare to identify themes. Our four investigation reports in this series span emergency care response, continuity of care, data sharing and IT, and needs assessments and disability access.
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Published
  • Theme:

    Emergency care, Communication and decision making, Continuity of care
  • Awaiting safety recommendation responses

A healthcare assistant wearing blue scrubs checks the blood sugar level of a male patient.

Insulin: supporting safe administration in inpatient settings

published
This investigation examines risks to safety when patients who take insulin are admitted to acute hospitals. Insulin is a high risk medication and remains one of the most common causes of harm from medication errors in the NHS.
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Published
  • Theme:

    Medication, Long-term conditions, Hospital care
  • Awaiting safety recommendation responses

A young diabetic woman holds a syringe pen to inject insulin.

Insulin: supporting safe self-administration in vulnerable patient groups in the community

published
This series of reports explores risks to patient safety for patients in the community who self-administer insulin and who may be at increased risk of harm because of their circumstances.
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Published
  • Theme:

    Mental health, Medication, Learning disabilities
  • Awaiting safety recommendation responses

A doctor wearing blue scrubs uses a laptop. A graphic of computer folders to represent electronic patient record systems is superimposed on the photo.

Electronic patient record systems – electronic referrals for ongoing care

We have launched an investigation that explores risks to patient safety where electronic patient record (EPR) systems, introduced to support referrals for patient care, have contributed to harm from missed or delayed care.
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Launched
  • Theme:

    Access to care, Follow-up care, Continuity of care
Hands type on a laptop keyboard. Nine exclamation marks are superimposed over the photo, including one in a warning triangle, to signify an issue with the computer system.

Electronic patient record systems – risk from loss of functionality

We have launched an investigation that explores risks to patient safety where access to, the use of, or functionality of electronic patient record (EPR) systems has been lost. That loss may be short- or long-term, and be planned or unplanned.
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Launched
  • Theme:

    Communication and decision making, Medical tests, Continuity of care
A male nurse kneels next to a female patient laying in a bed on a hospital corridor.

Patient care in temporary care environments

published
This investigation explores the management of patient safety risks associated with using temporary care environments, often referred to as ‘corridor care’ and ‘temporary escalation spaces’.
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Published
  • Theme:

    Acute, Emergency care, Patient safety themes
A man in scrubs intently using a tablet computer in a clinical setting.

Electronic patient record (EPR) systems – thematic review

published
This thematic review of 50 HSSIB reports identifies specific patient safety issues and learning related to EPR systems. The report includes a safety observation and local-level learning prompts around safe selection and procurement, implementation and ongoing optimisation of EPR systems.
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Published
  • Theme:

    NHS staff, Communication and decision making, Medical devices
Close-up of  man with a closely trimmed beard. He takes a pill with a glass of water.

The prescribing of lithium for bipolar disorder

Around 1 in 50 adults experience bipolar disorder within their lives. Whilst the number of people with bipolar disorder has remained consistent over time the prescribing of lithium has been in decline for decades.
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Launched
  • Theme:

    Mental health, Medication
Collage of enlarged eyes seen through hand held magnifying glasses.

Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development

published
We are working on a report to share learning gained from our investigation activities and education programme about patient safety incident investigations under the Patient Safety Incident Response Framework (PSIRF).
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Published
  • Theme:

    NHS staff, Patient safety themes, Patient and family
Young woman wearing a baggy long sleeve jumper meets with her doctor.

Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)

We have launched three investigations to provide examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF).
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Launched
  • Theme:

    Mental health, Hospital care, Patient safety themes
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