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Investigations and reports

As part of our national investigations programme, we publish bulletins and a final report with safety recommendations for each investigation. These documents are available to download as PDFs from individual investigation pages and in accessible format. We also publish responses from national bodies to our safety recommendations on individual investigation pages.

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CPAP machine

Treating COVID-19 patients using Continuous Positive Airway Pressure (CPAP)

We have launched an investigation into the safety risk of treating patients with coronavirus (COVID-19) with Continuous Positive Airway Pressure Ventilation (CPAP) outside of critical care units.
Read the summary
Launched
  • Theme:

    Respiratory, COVID-19
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The use of an appropriate infusion fluid when flushing arterial lines

This investigation will look at the risks to critically ill patients when the wrong fluid is attached to an arterial line.
Read the summary
Launched
  • Theme:

    Cardiac
Two doctors discussing results on a clipboard.

HSIB local integrated investigation pilot

HSIB has launched a pilot programme to evaluate its ability to carry out effective locality-based investigations. Following evaluation, consideration will be given as to whether this model can be implemented more widely by HSIB.
Read the summary
Launched
  • Theme:

    Analysis
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Wrong site surgery – wrong patient: invasive procedures in outpatient settings

published
We have started an investigation looking 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
  • Awaiting safety recommendation responses

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Prescribing and administering insulin from a pen device in hospital

We’ve launched a national investigation looking at administering insulin from a pen device in hospitals.One in six hospital beds in England are occupied by someone who has diabetes. In 2017 there were 260,000 people with diabetes in the UK who experienced a medication error.
Read the summary
Launched
  • Theme:

    Checking, Medication
Mock up image of the report investigating the inadvertent administration of an oral liquid into a vein

Inadvertent administration of an oral liquid into a vein

published
This investigation emphasises that complex and fragmented medicine safety processes are putting patients across the country at risk. The report puts forward recommendations aimed at driving national improvement to reduce potentially fatal medication errors.
Read the summary
Published
  • Theme:

    Checking, Medication
  • Safety recommendation responses received

Image of patient in hospital bed

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.
Read the summary
Published
  • Theme:

    Emergency care, Communication and decision making
  • Safety recommendation responses received

Image of blurred hospital

Provision of mental health care to patients presenting at the emergency department

published
In England, it is estimated that 5% of all hospital emergency department attendances are primarily due to mental ill-health.This investigation reinforces the need for emergency mental health care 24 hours a day, seven days a week.
Read the summary
Published
  • Theme:

    Mental health, Access to care
  • Safety recommendation responses received

Mock up image of the report investigating the design and safe use of portable oxygen systems

Design and safe use of portable oxygen systems

published
NHS Improvement issued a patient safety alert on medical devices in January 2018. It highlighted 400 incidents - including six deaths - over three years that involved the incorrect operation of oxygen cylinder controls. This investigation reinforces that alert and makes further safety recommendatio…
Read the summary
Published
  • Theme:

    Medical devices, Checking
  • Safety recommendation responses received

Mock up image of the report investigating the piped supply of medical air and oxygen

Piped supply of medical air and oxygen

published
This investigation focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.
Read the summary
Published
  • Theme:

    Never events
  • Safety recommendation responses received