Patient safety investigations

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A male patient lays asleep in a hospital bed.
HSIB legacy content

Management of chronic health conditions in prisons

published
Each day around 120 prisoners with ongoing medication needs are moved between prisons. This investigation identifies opportunities and remedies that could be applied across the system to reduce the risk of prisoners with long term, chronic conditions being moved without crucial medication.
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Published

  • Theme:

    Long-term conditions, Access to care

  • Safety recommendation responses received

Blood samples in tubes with red and blue caps.
HSIB legacy content

Wrong patient details on blood sample

published
Wrong blood in tube (WBIT) incidents can occur when blood samples are taken from patients and are either miscollected (blood is taken from the wrong patient but labelled with the correct patient details) or mislabelled (blood is taken from the intended patient but labelled with the incorrect patien…
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Published

  • Theme:

    Checking, Medical tests

  • Safety recommendation responses received

Two emergency call centre workers sit next to each other wearing headsets.
HSIB legacy content

Management of acute onset testicular pain

published
This investigation looks at delayed diagnosis of testicular torsion. This is a condition where the testicle twists, cuts off the blood supply and results in significant pain. If not treated in time it can result in the loss of a testicle.
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Published

  • Theme:

    Emergency care, Access to care

  • Safety recommendation responses received

Button batteries.
HSIB legacy content

Undetected button/coin cell battery ingestion in children

published
This investigation looks at the undetected ingestion of button/coin cell batteries in children. It follows a reference event where a child died following the unknown and undetected ingestion of a coin cell battery.
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Published

  • Theme:

    Emergency care, Communication and decision making

  • Safety recommendation responses received

X-ray of a shoulder and chest.
HSIB legacy content

Failures in communication or follow-up of unexpected significant radiological findings

published
X-rays are the most common radiological examination. 22.9 million were carried out in the NHS in 2016/17. Failures in communication or follow-up of unexpected significant radiological findings is a nationally recognised patient safety risk. 
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Published

  • Theme:

    Access to care, Medical tests

  • Safety recommendation responses received

The screen of a patient monitor in a hospital.
HSIB legacy content

Recognising and responding to critically unwell patients

published
Problems in recognising and responding to deteriorating patients continues to be a major source of severe harm and preventable death in hospitals. Previous research has shown that up to a quarter of preventable deaths are related to failures in clinical monitoring.
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Published

  • Theme:

    Communication and decision making, Hospital care

  • Safety recommendation responses received

An adult hand holds a child's hand with a bandaged intravenous (IV) line.
HSIB legacy content

Inadvertent administration of an oral liquid into a vein

published
This investigation emphasises that complex and fragmented medicine safety processes are putting patients across the country at risk. The report puts forward safety recommendations aimed at driving national improvement to reduce potentially fatal medication errors.
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Published

  • Theme:

    Medication, Checking

  • Safety recommendation responses received

Oxygen valve.
HSIB legacy content

Piped supply of medical air and oxygen

published
This investigation focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.
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Published

  • Theme:

    Never events

  • Safety recommendation responses received

Blurred rear doors of an ambulance.
HSIB legacy content

Transfer of critically ill adults

published
This investigation looks at the transfer of critically ill adults. It has previously been referred to as 'Cardiac and vascular pathways', but the original investigation was split. This is part one of the investigation.
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Published

  • Theme:

    Access to care, Hospital care

  • Safety recommendation responses received

Portable oxygen cylinder on a hospital ward.
HSIB legacy content

Design and safe use of portable oxygen systems

published
NHS Improvement issued a patient safety alert on medical devices in January 2018. It highlighted 400 incidents - including six deaths - over three years that involved the incorrect operation of oxygen cylinder controls. This investigation reinforces that alert and makes further safety recommendatio…
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Published

  • Theme:

    Medical devices, Checking

  • Safety recommendation responses received

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