Patient safety investigations

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Older person in bed at home holding a mug and speaking with a carer seated beside the bed, with a bedside lamp and wooden headboard in the background.

Safety accountability and oversight thematic review

We have launched a thematic review of HSIB and HSSIB investigation reports, covering the period April 2017 to April 2026, that explores patient safety accountability and oversight.
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Launched

  • Theme:

    Long-term conditions, Patient safety themes, Continuity of care
Close up of hands using a smart phone.

Online prescribing: challenges and opportunities to improve patient safety

published
This investigation looks at the complex regulatory landscape around independent online prescribing and challenges sharing patient information between the NHS and independent online prescribing services.
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Published

  • Theme:

    Medication

  • Awaiting safety recommendation responses

A stylised illustration of a healthcare pathway made up of connected circular icons in blue and green. The icons include a heart monitor, stethoscope, ambulance, pills, syringe, DNA strand, test tube and medical cross, all linked by a flowing line to represent joined-up care.

Patient safety across regional care pathways: learning from an HSSIB investigation pilot

published
We've identified patient safety risks across regional care pathways, linked to unclear roles, limited oversight and inconsistent information sharing which can limit how risks are identified and managed across NHS organisations.
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Published

  • Theme:

    Communication and decision making, Access to care, Continuity of care
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 completed three local investigations and a national investigation that look at medication related harm.
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Published

  • Theme:

    Medication, Communication and decision making, Continuity of 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

Young woman wearing a baggy long sleeve jumper meets with her doctor.

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

published
These three investigations provide examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF). Currently, one of three investigation reports has been published.
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Launched

  • Theme:

    Mental health, Hospital care, Patient safety themes
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 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
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