Get updates via RSS feed
HSIB legacy content
Missed detection of lung cancer on chest X-rays of patients being seen in primary care
published
This investigation looks into the safety risk of delayed diagnosis of lung cancer. Specifically, the investigation explores delays in patients being seen in primary care and who had a chest X-ray that had not detected cancer.
Read the summary
Published
-
Theme:
Missed diagnosis -
Safety recommendation responses received
HSIB legacy content
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June 2020
published
The number of intrapartum stillbirths referred to the Healthcare Safety Investigation Branch (HSIB) between April and the end of June 2020 increased compared to the same time in the previous year. The data initiated an HSIB national learning report which explored the findings from our maternity inv…
Read the summary
Published
-
Theme:
Maternity, Coronavirus (COVID-19) -
Safety recommendation responses received
HSIB legacy content
A thematic analysis of HSIB's first 22 national investigations
published
HSIB has analysed its first 22 HSIB national investigations to identify the recurring patient safety themes and to explore the impact so far of the 85 recommendations we have made to address them. The work was undertaken after it was recognised that similar issues were arising in our investigations…
Read the summary
Published
-
Theme:
Analysis
HSIB legacy content
Timely detection and treatment of cauda equina syndrome
published
We have identified a patient safety risk involving the timely detection and treatment of non-malignant spinal cord compression (cauda equina syndrome).
Read the summary
Published
-
Theme:
Emergency care, Access to care -
Safety recommendation responses received
HSIB legacy content
Suitability of equipment and technology used for continuous fetal heart rate monitoring
published
This national patient safety investigation looks into the suitability of equipment and technology used for continuous fetal heart rate monitoring during labour and birth.
Read the summary
Published
-
Theme:
Maternity, Medical devices -
Safety recommendation responses received
HSIB legacy content
Oxygen issues during the COVID-19 pandemic
published
There has been an increased demand for oxygen gas in hospital wards during the COVID-19 pandemic. COVID-19 can cause severe inflammation of the lungs affecting a patient’s ability to breathe. This investigation looks at the provision of piped oxygen gas supplies to hospitals.
Read the summary
Published
-
Theme:
Medical devices, Coronavirus (COVID-19) -
Safety recommendation responses received
HSIB legacy content
Wrong site surgery – wrong patient: invasive procedures in outpatient settings
published
This investigation looks at the risks involved in the correct identification of patients in outpatient departments. Correct identification is crucial to make sure they receive the right clinical procedure.
Read the summary
Published
-
Theme:
Checking, Surgical -
Safety recommendation responses received
HSIB legacy content
Management of chronic asthma in children aged 16 years and under
published
Asthma is the most common lung disease in the UK. 1.1 million children are diagnosed with the condition. Our investigation looks at the risks involved in the management of children aged 16 years and under diagnosed with asthma.
Read the summary
Published
-
Theme:
Long-term conditions, Access to care -
Safety recommendation responses received
HSIB legacy content
Outpatient appointments intended but not booked after inpatient stays
published
We identified a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient stay. If a patient does not receive their intended follow-up appointment, it could lead to patient harm owing to delayed or absent clinical care and treatment.
Read the summary
Published
-
Theme:
Access to care, Follow-up care -
Safety recommendation responses received
HSIB legacy content
Wrong site surgery – wrong tooth extraction
published
Wrong tooth extraction is the most common form of wrong site surgery reported over the past five years. This is classed as a Never Event - patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at …
Read the summary
Published
-
Theme:
Checking, Surgical -
Safety recommendation responses received