Patient safety investigations

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Healthcare professional in scrubs.
HSIB legacy content

Early warning scores to detect deterioration in COVID-19 inpatients

published
This national intelligence report provides insight into a safety risk when using early warning scores to detect deterioration in patients with coronavirus (COVID-19) on general hospital wards.
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Published

  • Theme:

    Hospital care, Coronavirus (COVID-19)
Lab test.
HSIB legacy content

Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection

published
In February 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. These initial investigations were carried out between April 2018 and December 2019. One of the themes highlighted w…
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Published

  • Theme:

    Maternity, Communication and decision making
A radiographer's hand operates an ultrasound scanner.
HSIB legacy content

Summary of themes arising from the HSIB maternity programme

published
This national learning report highlights the themes emerging from the initial investigations carried out as part of our maternity investigation programme. It looks at maternity investigations carried out by HSIB between April 2018 and December 2019.
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Published

  • Theme:

    Maternity, Patient safety themes
A radiographer prepares a patient for an MRI scan.
HSIB legacy content

Undiagnosed cardiomyopathy in a young person with autism

published
People with additional needs receiving care in hospital may require adjustments to promote their safety and improve their experience of care. This investigation seeks to understand the safety risks associated with patients with additional needs.
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Published

  • Theme:

    Long-term conditions, Communication and decision making

  • Safety recommendation responses received

Ultrasound scanning equipment.
HSIB legacy content

The diagnosis of ectopic pregnancy

published
An estimated 12,000 women experience an ectopic pregnancy each year in the UK. Ectopic pregnancy occurs when the fertilised egg implants outside the uterus, usually in the Fallopian tube. If it’s left untreated, it can rupture and cause internal bleeding.
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Published

  • Theme:

    Emergency care, Communication and decision making

  • Safety recommendation responses received

Yellow, blue and red prescription drug capsules.
HSIB legacy content

Potential under-recognised risk of harm from the use of propranolol

published
This patient safety investigation explores the under recognised toxicity of propranolol in overdose. Propranolol is used to treat medical conditions including migraine, cardiovascular problems and the physical effects of anxiety.
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Published

  • Theme:

    Medication, Communication and decision making

  • Safety recommendation responses received

A patient lies in a hospital bed with a monitor on their finger.
HSIB legacy content

Delayed recognition of acute aortic dissection

published
Acute aortic dissection is a relatively rare but life-threatening condition. It requires rapid recognition and urgent treatment in a specialist centre. The symptoms and signs can be confusing and aortic dissection may be mistaken for other conditions, leading to delay in diagnosis.
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Published

  • Theme:

    Emergency care, Communication and decision making

  • Safety recommendation responses received

A patient has an eye examination.
HSIB legacy content

Lack of timely monitoring of patients with glaucoma

published
Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month suffer severe or permanent sight loss as a result of the delays.
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Published

  • Theme:

    Access to care, Follow-up care

  • Safety recommendation responses received

A woman in labour grips her birth partner's hand.
HSIB legacy content

Detection of retained vaginal swabs and tampons following childbirth

published
Retained vaginal swabs are classed as a ‘never event’. A never event is a serious incident that is entirely preventable. Data compiled by NHS England/Improvement shows that accidental retention of vaginal swabs is the most common never event in the ‘retained foreign objects’ category.
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Published

  • Theme:

    Medical devices, Checking

  • Safety recommendation responses received

A healthcare professional taps a tablet computer.
HSIB legacy content

Electronic prescribing and medicines administration systems and safe discharge

published
We’ve identified a significant safety risk posed by poorly implemented electronic prescribing and medicines administration (ePMA) systems. An ePMA system supports the safe, effective, and cost-effective use of medicines from a patient’s admission to hospital until their discharge.
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Published

  • Theme:

    Medication, Access to care

  • Safety recommendation responses received

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