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.
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Launched
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Theme:
Respiratory, COVID-19
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.
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Launched
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Theme:
Cardiac
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.
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Launched
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Theme:
Analysis
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.
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Published
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Theme:
Checking, Surgical -
Awaiting safety recommendation responses
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.
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Launched
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Theme:
Checking, Medication
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.
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Published
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Theme:
Checking, Medication -
Safety recommendation responses received
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
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Theme:
Emergency care, Communication and decision making -
Safety recommendation responses received
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.
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Published
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Theme:
Mental health, Access to care -
Safety recommendation responses received
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…
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Published
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Theme:
Medical devices, Checking -
Safety recommendation responses received
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.
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Published
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Theme:
Never events -
Safety recommendation responses received