
Identification of critical patient information at the bedside – Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)
This investigation explores the challenges NHS hospital staff face when trying to access key information about their patients, at the patient bedside.
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Launched
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Theme:
Cardiac, Communication and decision making

Surgical care of NHS patients in independent hospitals
published
This investigation looks at the delivery of safe care to NHS-funded patients undergoing surgery within independent (private) hospitals.
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Published
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Theme:
Communication and decision making, Surgical -
Safety recommendation responses received

Recognition of the acutely ill infant
published
We were notified of a three-month-old infant who was admitted to hospital and discharged four hours later. The infant was re-admitted less than four hours later and sadly died of Meningococcus (serogroup B).
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Published
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Theme:
Emergency care, Communication and decision making

Administering high strength 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:
Medication, Checking

Unintentional overdose of morphine sulfate oral solution
published
In this investigation we share Len's story. He took an accidental overdose of morphine sulfate oral liquid while at home. We've made two safety observations, relevant to manufacturers of morphine liquids, and to encourage participation in HSIB investigations.
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Published
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Theme:
Medication

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 -
Safety recommendation responses received

Oxygen issues during the COVID-19 pandemic
published
We launched a national investigation into the provision of piped oxygen gas supplies to hospitals.There has been an increased demand for oxygen gas in hospital wards during the COVID-19 pandemic. COVID-19 can cause severe inflammation of the lungs affecting a patient’s ability to breathe.
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Published
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Theme:
Medical devices, Coronavirus (COVID-19) -
Safety recommendation responses received

Provision of care for children and young people when accessing specialist gender dysphoria services
published
This investigation explores the care of patients who present to child and adolescent mental health services (CAMHS) with questions about their gender identity and are referred to specialist gender dysphoria services.
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Published
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Theme:
Access to care -
Awaiting safety recommendation responses

Management of preterm labour and birth
Preterm birth is one of the main causes for under-five mortality (death) and disability worldwide. 60% of twin pregnancies result in premature birth. This investigation considers the existing knowledge and management of preterm labour and birth of twins.
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Launched
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Theme:
Maternity

Clinical decision making: diagnosis of pulmonary embolism in emergency departments
published
A person suffering from a pulmonary embolism (PE) requires urgent treatment to reduce the chance of significant harm or death. Any delay in recognising the symptoms of PE and treatment of the suspicion of PE increases risk that a patient may suffer harm.
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Published
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Theme:
Hospital care, Communication and decision making -
Awaiting safety recommendation responses