Patient safety investigations

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A blurred hospital corridor with a healthcare professional walking away and a drip stand in the foreground.
HSIB legacy content

Placement of nasogastric tubes

published
This investigation looks at nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice.
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Published

  • Theme:

    Medical devices, Checking

  • Safety recommendation responses received

A smart infusion pump at a patient's bedside.
HSIB legacy content

Procurement, usability and adoption of ‘smart’ infusion pumps

published
Although the aim of smart infusion pumps is to improve patient safety, the technology can introduce new risks. This investigation focused on understanding the challenges involved in introducing smart infusion pump technology within NHS hospitals.
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Published

  • Theme:

    Communication and decision making, Medical devices

  • Safety recommendation responses received

A woman lies on a hospital bed in labour.
HSIB legacy content

Delays to intrapartum intervention once fetal compromise is suspected

published
We have identified a safety risk in maternity care relating to delays to intrapartum intervention once fetal compromise is suspected. The term intrapartum refers to the period of time spanning the commencement of labour, the birth of the baby and the delivery of the placenta and membranes.
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Published

  • Theme:

    Maternity, Communication and decision making

  • Safety recommendation responses received

A hospital worker walks along a corridor.
HSIB legacy content

Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation

published
This prospective patient safety investigation looks at how hospitals can minimise the likelihood of patients catching coronavirus (COVID-19) on acute hospital wards.
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Published

  • Theme:

    Hospital care, Coronavirus (COVID-19)

  • Safety recommendation responses received

Empty hospital bed in a corridor.
HSIB legacy content

Unplanned delayed removal of ureteric stents

published
This investigation relates to patients with kidney stones who have had a ureteric stent inserted and where the stent is left in longer than planned.
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Published

  • Theme:

    Access to care, Follow-up care

  • Safety recommendation responses received

Blurred healthcare professionals rushing past empty beds on a hospital corridor.
HSIB legacy content

Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke

published
Every year in the UK over 100,000 people have a stroke. Patients who are admitted to hospital for any reason, including stroke, are assessed for their risk of developing blood clots in their veins which may arise due to being less active than usual.
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Published

  • Theme:

    Acute

  • Safety recommendation responses received

An unseen patient rests their hand on a hospital bed, with an unused cannula inserted on the top of their hand.
HSIB legacy content

The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital

published
Research suggests that 237 million medication errors occur at some point in the medication process in England per year. When errors occur in prescribing high-risk medications for older patients with multiple medical problems, there is a significant risk of serious harm. High-risk medicines are thos…
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Published

  • Theme:

    Medication, Communication and decision making

  • Safety recommendation responses received

An investigator sits with two family members filling in a form.
HSIB legacy content

Giving families a voice: HSIB’s approach to patient and family engagement during investigations

published
This national learning report highlights the themes emerging from our contact with families during our patient safety investigations. Our national learning reports describe common themes and findings that come out of our national investigation programme and our maternity investigation programme.
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Published

  • Theme:

    Patient and family
Healthcare worker wearing personal protective equipment (PPE).
HSIB legacy content

Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response

published
This national intelligence report provides insight into a safety risk related to PPE requirements for care workers delivering homecare during the COVID-19 response.
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Published

  • Theme:

    Coronavirus (COVID-19)
A mother holds her sleeping newborn baby.
HSIB legacy content

Neonatal collapse alongside skin-to-skin contact

published
In March 2020 we published a national learning report to highlight the themes emerging from the initial investigations carried out as part of our maternity investigation programme.
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Published

  • Theme:

    Maternity, Communication and decision making
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