David Fassam, Senior Safety Investigator, continues our series of blogs that take a look at the methods we use in our patient safety investigations. Next up is the Functional Resonance Analysis Metho…
Discrimination stops temporary workers speaking up about safety concerns
5 September 2024
Our latest investigation report reveals there is widespread discrimination against temporary staff in the NHS and this creates a culture of fear that stops them speaking up about patient safety.
Unnecessary 999 calls from prisons lead to a ‘significant’ loss in ambulance crew time
29 August 2024
Ambulance crews spend significant time diverting resources to 999 callouts in prisons that are cancelled or not a serious enough medical emergency, says our latest report.
Annual report sets out progress in our first six months
22 July 2024
Our first annual report and accounts, published today, covers the six months from our launch to 31 March 2024 and sets out our priorities as a new organisation, with achievements and progress to date.
Self-harm risk of patients under continuous observation in hospital wards
9 May 2024
Our latest investigation has found ‘limited evidence’ that the current approach to continuous observation of adult patients at risk of self-harm when on hospitals wards is effective.
Tackling health inequity: observations from an investigation visit
30 April 2024
Nichola Crust, Senior Safety Investigator, shares how one primary care network in the north of England is tackling health inequity by building relationships beyond traditional healthcare boundaries, …
We've investigated the risk of unintentional ‘retained’ swabs after invasive procedures. The investigation was launched after we examined the case of a patient who had two swabs left in her ches…
Temporary NHS staff a ‘lost voice’ in crucial patient safety investigations
14 March 2024
Our latest investigation has found that not involving temporary NHS staff in serious incident investigations may ‘undermine’ its ability to improve patient safety.
Senior Safety Investigator, Neil Alexander, blogs about the challenges facing the NHS in tackling the elective care backlog and how learning from our investigation reports may be able to help the NHS…
New learning report brings together learning on patient misidentification
8 February 2024
Our latest report reiterates that the misidentification of patients remains a persistent safety risk across the NHS but is one that is under-recognised and under-researched.
New report charts safety risks associated with managing patients with known ‘difficult airways’ in emergency situations
25 January 2024
Our latest report shows improvement is needed at a national level in the communication, preparation and planning for patients who may have ‘a difficult airway’ – that is the anatomy of their mouth, t…
Continuing our series of blogs that look at the range of investigation methods we use, Deinniol Owens and Dr Helen Vosper highlight how SEIPS can be the investigator’s ‘swiss army knife’ when plannin…
This week marks three months since an event was held at Kings College London to formally recognise our formal establishment as the Health Services Safety Investigations Body (HSSIB).
Electronic patient record systems: recurring themes arising from safety investigations
19 December 2023
Senior Safety Investigator, Helen Jones, blogs about some of the key benefits and risks of electronic patient record (EPR) systems used in healthcare, sharing what we are learning from our safety inv…
Change needed in how GP continuity of care is prioritised at a national level
30 November 2023
Making continuity of care an ‘essential requirement’ for GP practices could reduce the risk of a delay in diagnosing serious health conditions, and ease significant pressure on GP’s workload and welf…
Investigation explores risk of patients not receiving crucial medication through a portable medical device
14 November 2023
Alarms on a portable medical device may not notify staff that medication is not being delivered as it should, creating a ‘hazardous situation’ and increasing the risk of harm to patients.
New report shows needs of learning disability patients ‘not consistently met’ when they are in hospital
2 November 2023
Despite national efforts to address inequity, the health and care system is not always meeting the needs of people with a learning disability when they are cared for in hospital, says our latest repo…
Amber Sargent and Helen Jones blog about the patient safety issues that arise when the impact of menopause on mental health is not considered during clinical assessments.
HSSIB officially launches with aim to drive radical change in patient safety
18 October 2023
As our newly formed investigation body officially launched today, clear messages came from our leadership team that we will aim to drive ‘radical’ change in how patient safety is managed across healt…
Report explores ‘proactive and integrated approach’ to managing safety in healthcare
18 October 2023
Today we publish our first report as the Health Services Safety Investigations Body, exploring the use of safety management systems and how they could contribute to more effective safety management i…
Philippa Styles appointed as Director of Investigations
16 October 2023
Philippa Styles will join our team shortly as Director of Investigations. This is a critical role within the leadership team, overseeing all investigations undertaken by the Health Services Safety In…
The importance of non-patient facing NHS services in patient safety
19 July 2023
Senior Safety Investigators Russell Evans and Craig Hadley highlight how behind-the-scenes services are crucial to help the NHS operate effectively and safely, in our latest blog.
Helping NHS staff to do their jobs: design of information in the workplace
29 June 2023
Senior Safety Investigators Clare Crowley and Nick Woodier blog about the simple but often overlooked measures that NHS staff and organisations can take to improve the design and display of informati…
The investigator's toolkit: Using Appreciative Inquiry in safety investigations
5 June 2023
In the first in a series of blogs looking at the range of investigation methods we use, Nichola Crust reflects on how Appreciative Inquiry can be used to examine patient safety and identify opportuni…
Failing to communicate: challenges with electronic communication systems
18 April 2023
Matt Mansbridge and Melanie Ottewill blog about the patient safety issues that arise when systems are unable to communicate with each other, as highlighted in three of our national investigations to …
The importance of equipment design in patient safety
10 January 2023
Laura Pickup blogs about equipment design in healthcare and asks whether NHS staff should be held accountable for the use of devices and equipment leading to patient safety events.
Jonathan Back, Analyst, blogs about the opportunities the healthcare system has to adopt a proactive risk management approach to improve patient safety.
The impact of reorganising NHS services on patient safety
5 January 2023
Scott Hislop, Deputy Director of Investigations, looks at the challenges faced by the NHS when flexing to meet demands and how to mitigate potential risks to patient safety.
Supporting NHS staff involved in patient safety investigations
19 December 2022
In this blog, Matthew Wain highlights how NHS organisations can support staff with patient safety investigations, and more generally, in the face of increased pressure.
Maintaining family involvement in the face of winter pressures
6 December 2022
Louise Pye highlights how the Patient Safety Incident Response Framework can help NHS trusts involve patients and families in the face of extreme winter pressures.
Bill Kirkup speaks to HSIB staff about 'Reading the signals'
17 November 2022
Our Clinical Director of Maternity Investigations shares the details of a seminar delivered to HSIB staff by Dr Bill Kirkup CBE as part of our investigation education programme.
PSIRF and the HSIB: supporting how the NHS responds to patient safety incidents
9 November 2022
In this blog Melanie Ottewill explains how our work is supporting the NHS to adopt a systems approach to local safety investigations through the Patient Safety Incident Response Framework (PSIRF).
How patients’ voices can improve safety in the health service in relation to medicines and medical devices
8 November 2022
Following her seminar with HSIB staff last month, this guest blog post from Henrietta Hughes introduces her vision for her new role as Patient Safety Commissioner.
Reviewing our new powers and how they will impact you
11 October 2022
The Health and Care Act 2022 will establish HSIB as the Health Services Safety Investigations Body (HSSIB) in April 2023 - a fully independent arm’s-length body. In addition to our statutory independ…
PSIRF: a fundamental shift in how the NHS responds to patient safety incidents
27 September 2022
As part of our investigation education seminar series for our staff, NHS England’s Tracey Herlihey, Head of Patient Safety Incident Response Policy and Lauren Mosley, Head of Patient Safety Implement…
Looking beyond the recommendation: building a holistic approach to safety improvement
8 September 2022
As part of our investigation education seminar series for our staff, healthcare improvement expert Professor Mary Dixon-Woods joined us for our August session. In this blog, Ian Lavery rounds-up her …
How we’ve worked with NHS England and Learn Together to help give families a voice
26 August 2022
Coinciding with the publication of the Patient Safety Incident Response Framework (PSIRF) by NHS England, Louise Pye, Head of Family Engagement at HSIB, reflects on her involvement in producing the s…
Integrating restorative justice into patient safety investigation
29 July 2022
As part of our investigation education lectures for HSIB staff, this month we welcomed Jo Wailling, Senior Research Fellow at Te Herenga Waka - Victoria University of Wellington, New Zealand.
In 2017 HSIB was the first organisation in the world set up to improve patient safety through independent investigations without blame.Now we’re not alone though, as Norway were hot on our heels with…
Zero avoidable deaths – an aspiration, not a target
8 June 2022
Melanie Ottewill, Senior Safety Investigator and Senior Investigation Science Educator, shares her thoughts on our internal seminar where our guest speaker was Jeremy Hunt MP.