Patient safety investigations

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Ambulance crew with patient
HSIB legacy content

Harm caused by delays in transferring patients to the right place of care

published
This investigation explores issues around patient handover to emergency care. Patients who wait in ambulances at an emergency department are at potential risk of coming to harm due to deterioration or not being able to access timely and appropriate treatment.
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Published

  • Theme:

    Emergency care

  • Awaiting safety recommendation responses

Operating theatre
HSIB legacy content

The selection and insertion of vascular grafts in haemodialysis patients

published
Almost 30,000 people in the UK currently receive dialysis. This investigation looks at associated patient safety risks in operating theatres, and packaging of vascular grafts.
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Published

  • Theme:

    Medical devices, Surgical, Coronavirus (COVID-19)

  • Safety recommendation responses received

Healthcare professional holds a patient's hand
HSIB legacy content

Variations in the delivery of palliative care services to adults

published
This national investigation looks at variations in delivery of palliative care services to adults in England, by the NHS, charities and private sector.
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Published

  • Theme:

    Access to care

  • Safety recommendation responses received

A Black patient lies in a hospital bed with their eyes closed.
HSIB legacy content

Invasive procedures in patients with sickle cell disease

published
This investigation looks at the risks for patients with sickle cell disease when they undergo invasive procedures in hospital. It explores how hospital specialities can ensure that patients with sickle cell disease are prepared for procedures which could put them at risk of a sickle cell crisis.
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Published

  • Theme:

    Long-term conditions, Communication and decision making

  • Safety recommendation responses received

A woman laying in a hospital bed talks to a male nurse wearing a face mask and blue scrubs.
HSIB legacy content

Management of sickle cell crisis

published
Sickle cell disease is the name for a group of inherited health conditions that affect the red blood cells. It affects approximately 15,000 people in the UK. This investigation looks at the risks for patients with sickle cell disease when they are treated with morphine for a sickle cell crisis.
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Published

  • Theme:

    Long-term conditions, Medical devices, Coronavirus (COVID-19)

  • Safety recommendation responses received

A clinician wearing a surgical mask types on a laptop on a hospital ward.
HSIB legacy content

Clinical investigation booking systems failures: written communications in community languages

published
This investigation looks at the safety risk of booking systems failures. We explore the use of paper and hybrid booking systems and the production of appointment letters.
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Published

  • Theme:

    Communication and decision making

  • Safety recommendation responses received

Entrance to a hospital Emergency Department.
HSIB legacy content

Non-accidental injuries in infants attending the emergency department

published
This investigation explores the challenges for clinicians associated with making the clinical judgement as to whether an injury is accidental or not. Please note that due to the subject matter of this report it contains details which some readers may find distressing.
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Published

  • Theme:

    Missed diagnosis

  • Safety recommendation responses received

A central venous catheter (CVC) machine used for haemodialysis in kidney patients.
HSIB legacy content

Safety risk of air embolus associated with central venous catheters used for haemodialysis treatment

published
This investigation aims to improve patient safety by supporting healthcare staff in the safe use of central venous catheters to access a patient’s blood supply.
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Published

  • Theme:

    Medical devices

  • Safety recommendation responses received

Illustration of a lit up brain hovering over an outstretched palm.
HSIB legacy content

Care delivery within community mental health teams

published
In 2018, there were 1,306 suicides in England by people who had been in contact with mental health services in the previous 12 months. This investigation emphasises that NHS trusts should move away from standardised scoring tools that categorise a patient as high, medium or low risk, as they are a …
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Published

  • Theme:

    Mental health

  • Safety recommendation responses received

A pregnant woman lays back, cradling her bump.
HSIB legacy content

Assessment of risk during the maternity pathway

published
Despite a wealth of national guidance, risk assessments in the maternity pathway remain a significant challenge. This national learning report highlights the need for a personalised and dynamic risk assessment approach.
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Published

  • Theme:

    Maternity
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