Patient safety investigations

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An older man lies on a bed with his worried wife sitting with him, holding his hand.
HSIB legacy content

Unintentional overdose of morphine sulfate oral solution

published
In this investigation we share Len's story. He took an accidental overdose of morphine sulfate oral liquid while at home. We've made two safety observations, relevant to manufacturers of morphine liquids, and to encourage participation in HSIB investigations.
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Published

  • Theme:

    Medication
Two young people wearing rainbow bracelets hold hands outside in the sunshine.
HSIB legacy content

Provision of care for children and young people when accessing specialist gender dysphoria services

published
This investigation explores the care of patients who present to child and adolescent mental health services (CAMHS) with questions about their gender identity and are referred to specialist gender dysphoria services.
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Published

  • Theme:

    Access to care

  • Safety recommendation responses received

A London ambulance pulls up outside the Emergency Department at a hospital.
HSIB legacy content

Clinical decision making: diagnosis of pulmonary embolism in emergency departments

published
A person suffering from a pulmonary embolism (PE) requires urgent treatment to reduce the chance of significant harm or death. Any delay in recognising the symptoms of PE and treatment of the suspicion of PE increases risk that a patient may suffer harm.
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Published

  • Theme:

    Communication and decision making, Hospital care

  • Safety recommendation responses received

The exterior front entrance of a hospital emergency department, with ambulances parked outside.
HSIB legacy content

Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to emergency care

published
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.
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Published

  • Theme:

    Emergency care
A sleeping newborn baby with brown hair wears an oxygen mask, with a plaster holding a tube in place on their face.
HSIB legacy content

Emergency neonatal blood transfusion at birth following acute blood loss during labour and/or delivery

published
This investigation looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. Delays in neonatal blood transfusion emerged as a safety risk from investigations carried out under our maternity investigation programme.
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Published

  • Theme:

    Maternity, Neonatal

  • Safety recommendation responses received

An older person with short, grey hair lays in a hospital bed. They have an unhappy look on their face.
HSIB legacy content

Unintentional overdose of paracetamol in adults with low bodyweight

published
This investigation explores the prescription of oral paracetamol in adult inpatients who, on admission to hospital, have low bodyweight (less than 50kg).
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Published

  • Theme:

    Medication
A pregnant woman with short blonde hair stands in her living room with one hand on her bump, while making a phone call.
HSIB legacy content

Maternity pre-arrival instructions by 999 call handlers

published
This national investigation aims to improve patient safety for women and pregnant people waiting for an ambulance because of a pregnancy issue. It was launched after similar concerns were identified in 15 HSIB maternity investigations.
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Published

  • Theme:

    Maternity, Emergency care

  • Safety recommendation responses received

A male doctor wearing a white coat injects medication into the arm of a young boy.
HSIB legacy content

Weight-based medication errors in children

published
Studies show that prescribing errors are the most frequent type of medication error in children’s inpatient settings. This investigation looks at the risks involved when prescribing, dispensing and administering medicine to children.
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Published

  • Theme:

    Medication, Checking

  • Safety recommendation responses received

Ambulance parked outside Emergency Department.
HSIB legacy content

Local integrated investigation pilot 2: Incorrect patient details on handover

published
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.
Read the summary
Published

  • Safety recommendation responses received

Emergency Department (A&E) sign.
HSIB legacy content

Recognition of the acutely ill infant

published
We were notified of a three-month-old infant who was admitted to hospital and discharged four hours later. The infant was re-admitted less than four hours later and sadly died of Meningococcus (serogroup B).
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Published

  • Theme:

    Emergency care, Communication and decision making

  • Safety recommendation responses received

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