Patient safety investigations

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A young burnt out doctor sits resting his chin on his hands.

The impact of staff fatigue on patient safety

published
Staff fatigue contributes directly and indirectly to patient harm. Yet fatigue is not routinely considered in patient safety event reporting or learning reviews. We share safety recommendations and learning for healthcare organisations to increase their understanding of staff fatigue. This includes…
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Published

  • Theme:

    NHS staff, Patient safety themes

  • Awaiting safety recommendation responses

A district nurse cares for an elderly man with a head injury in his living room at home.

Workforce and patient safety

published
The workforce challenges faced by the NHS in England present a significant risk to patient safety and staff wellbeing. We're undertaking five investigations to consider how working conditions can be optimised to support patient safety, while maintaining and improving NHS staff wellbeing.
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Published

  • Theme:

    NHS staff, Patient safety themes

  • Awaiting safety recommendation responses

A young woman with a pained expression lies in an ambulance with her eyes closed while two paramedics treat her.

Pre-hospital interpretation of electrocardiograms (ECG) in ambulance services

published
These two investigations will help to address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST Elevated Myocardial Infarction (StEMI).
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Published

  • Theme:

    Emergency care, Cardiac

  • Awaiting safety recommendation responses

A female nurse gives an older woman medical pills.

Medication related harm

published
Medication is the most common intervention for patients in the NHS. In the most serious cases, delayed and missed medication can cause catastrophic effects. We have launched three local investigations and one national investigation into medication related harm. Two reports have been published so fa…
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Published

  • Theme:

    Medication, Communication and decision making, Continuity of care
A man in scrubs intently using a tablet computer in a clinical setting.

Electronic patient record (EPR) systems – thematic review

We have launched a thematic review of HSSIB’s work to date to identify specific patient safety issues and learning related to electronic patient record (EPR) systems.
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Launched

  • Theme:

    NHS staff, Communication and decision making, Medical devices
A smiling health visitor wearing green scrubs helps an older woman to walk in her home.

Safety management

published
This investigation considers how safety management is coordinated and integrated across the healthcare system. It looks at accountability beyond organisational boundaries and involving NHS staff and patients.
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Published

  • Theme:

    NHS staff, Patient safety themes, Patient and family, Continuity of care

  • Awaiting safety recommendation responses

A blurred hospital corridor with bright ceiling lights.

Mental health inpatient settings

published
This series of patient safety investigations look at mental health inpatient settings. They were directed by the Secretary of State for Health and Social Care.
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Published

  • Theme:

    Mental health

  • Awaiting safety recommendation responses

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 team is visiting prisons across England to investigate emergency care, continuity of care and data sharing and IT. Second report of four now published.
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Published

  • Theme:

    Emergency care, Communication and decision making, Continuity of care

  • Awaiting safety recommendation responses

Healthcare worker with head in hands

Sexual safety: the implications for patient safety

published
There is evidence of widespread sexism, sexual misconduct and harassment in healthcare. Between May and September 2024, we carried out exploratory work to consider the potential of conducting an investigation into patient safety risks associated with sexual safety.
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Published

  • Theme:

    NHS staff, Patient and family
A nurse holds the hands of a patient. You can't see their heads, the focus is on their arms.

Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare

published
Independent report published by the Health Services Safety Investigations Body and arm's-length body members of the Recommendations to Impact Collaborative Group.
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Published

  • Theme:

    Patient safety themes
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