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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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An unseen patient rests their hand on a hospital bed, with an unused cannula inserted on the top of their hand.

The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital

published
Research suggests that 237 million medication errors occur at some point in the medication process in England per year.When errors occur in prescribing high-risk medications for older patients with multiple medical problems, there is a significant risk of serious harm. High-risk medicines are those…
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Published
  • Theme:

    Communication and decision making, Medication
  • Safety recommendation responses received

Image of birth parent and newborn baby

Neonatal collapse alongside skin-to-skin contact

published
In March 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.
Read the summary
Published
  • Theme:

    Communication and decision making, Maternity
Mock up image of the report investigating the summary of themes arising from the HSIB maternity programme

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.
Read the summary
Published
  • Theme:

    Patient safety themes, Maternity
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