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 inve…
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Published
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Theme:
COVID-19, Maternity -
Awaiting safety recommendation responses
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 looked at the risks involved in the management of children aged 16 years and under diagnosed with asthma.
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Published
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Theme:
Long-term conditions, Access to care -
Safety recommendation responses received
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
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Theme:
Analysis
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
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Theme:
Access to care, Follow-up care -
Safety recommendation responses received
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.
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Published
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Theme:
Access to care, Follow-up care -
Awaiting safety recommendation responses
Decontamination of surgical instruments
This investigation seeks to explore what systems are in place to manage the decontamination process and prevent incorrectly decontaminated surgical instruments from being used on patients.
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Launched
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Theme:
Hospital care, Surgical
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
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Theme:
Emergency care, Access to care -
Awaiting safety recommendation responses
Emergency response to heart attack
published
Our investigation looked at the emergency response to heart attack across the NHS in England.
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Published
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Theme:
Emergency care, Access to care -
Safety recommendation responses received
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
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Theme:
Medical devices, Communication and decision making -
Safety recommendation responses received
Wrong site surgery – wrong tooth extraction
published
Our investigation looked at the risks to identifying the correct tooth for extraction in dental practice.
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Published
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Theme:
Checking, Surgical -
Safety recommendation responses received