Patient safety investigations

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

Local integrated investigation pilot 1: Incorrect patient identification

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:

    Analysis

  • Safety recommendation responses received

A male patient in a hospital bed wears a ventilator whilst he is treated for coronavirus (Covid-19).
HSIB legacy content

Treating Covid-19 patients using continuous positive airway pressure (CPAP) outside of a critical care unit

published
This investigation looked into the safety risk of treating patients with coronavirus (COVID-19) with Continuous Positive Airway Pressure Ventilation (CPAP) outside of critical care units.
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Published

  • Theme:

    Respiratory, Coronavirus (COVID-19)
Two surgeons in an operating theatre
HSIB legacy content

Surgical care of NHS patients in independent hospitals

published
This investigation looks at the delivery of safe care to NHS-funded patients undergoing surgery within independent (private) hospitals.
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Published

  • Theme:

    Communication and decision making, Surgical

  • Safety recommendation responses received

Chest X-ray.
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.
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Published

  • Theme:

    Missed diagnosis

  • Safety recommendation responses received

Maternity ward sign in a hospital.
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…
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Published

  • Theme:

    Maternity, Coronavirus (COVID-19)

  • Safety recommendation responses received

Colleagues gathered around a laptop screen.
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…
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Published

  • Theme:

    Analysis
An MRI scan of someone's lower spine
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).
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Published

  • Theme:

    Emergency care, Access to care

  • Safety recommendation responses received

Pregnant woman laying on a hospital bed, wearing a continuous fetal heart rate monitor.
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.
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Published

  • Theme:

    Maternity, Medical devices

  • Safety recommendation responses received

A man lays on a hospital bed breathing through an oxygen mask strapped to his face.
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.
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Published

  • Theme:

    Medical devices, Coronavirus (COVID-19)

  • Safety recommendation responses received

A young woman sits with her arms folded anxiously in a waiting area.
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.
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Published

  • Theme:

    Checking, Surgical

  • Safety recommendation responses received

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