Patient safety investigations

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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
A healthcare professional looks at notes at the hospital bedside of a patient lying on a bed behind them.
HSIB legacy content

Access to critical patient information at the bedside

published
This investigation explores the challenges NHS hospital staff face when trying to access key information about their patients, at the patient bedside.
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Published

  • Theme:

    Communication and decision making, Cardiac

  • Safety recommendation responses received

A newborn baby with yellowing of the whites of their eyes caused by jaundice.
HSIB legacy content

Detection of jaundice in newborn babies

published
Jaundice is a common condition in newborn babies, with 1 in 20 requiring treatment. This national investigation explores safety issues associated with delayed diagnosis of jaundice in newborn babies.
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Published

  • Theme:

    Missed diagnosis, Neonatal

  • Safety recommendation responses received

A heavily pregnant woman sits down to fill in a form.
HSIB legacy content

The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period

published
Venous thromboembolism is the collective term for the formation of blood clots, including deep vein thrombosis and pulmonary embolism. Pregnant women could suffer a potentially fatal blood vessel blockage if their risk is not properly assessed during pregnancy and the first six weeks after birth.
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Published

  • Theme:

    Maternity
Two healthcare workers have a conversation whilst walking along a hospital corridor.
HSIB legacy content

HSIB’s local investigation pilot: shared learning for local healthcare systems

published
Our local investigation pilot was launched to evaluate our ability to carry out effective locality-based patient safety investigations with actions aimed at specific NHS organisations, while still identifying and sharing relevant national learning.
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Published

  • Theme:

    Analysis, Emergency care
An NHS 111 call handler speaks into a headset.
HSIB legacy content

NHS 111’s response to callers with Covid-19-related symptoms during the pandemic

published
The purpose of this investigation is to support improvements in the delivery of NHS 111 and other telephone triage services during a national healthcare emergency.
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Published

  • Theme:

    Emergency care, Coronavirus (COVID-19)

  • Safety recommendation responses received

A mother holds the feet of premature twin babies.
HSIB legacy content

Management of preterm labour and birth of twins

published
Preterm birth is one of the main causes for under-five mortality (death) and disability worldwide. 60% of twin pregnancies result in premature birth. This investigation considers the existing knowledge and management of preterm labour and birth of twins.
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Published

  • Theme:

    Maternity
A nurse presses a button on a patient monitor in a critical care unit.
HSIB legacy content

The use of an appropriate flush fluid with arterial lines

published
This investigation aims to understand the risks for patients associated with blood sampling from arterial line systems used in adult critical care.
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Published

  • Theme:

    Medication, Medical devices, Checking

  • Safety recommendation responses received

A healthcare professional fills a syringe with medication.
HSIB legacy content

Administering high-strength insulin from a pen device in hospital

published
This patient safety investigation looks at administering insulin from a pen device in hospitals. In 2017 there were 260,000 people with diabetes in the UK who experienced a medication error.
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Published

  • Theme:

    Medication, Checking
Blue capsules spill out of a foil packet.
HSIB legacy content

Medicine omissions in learning disability secure units

published
This investigation looks at patients on learning disability secure units who do not receive medicines that have been prescribed to them.
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Published

  • Theme:

    Medication, Access to care

  • Safety recommendation responses received

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