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Agenda: Healthcare Safety Investigations Conference 2021

Just under a week to go to our biggest Healthcare Safety Investigations Conference yet.
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16 September: Healthcare Safety Investigations Conference

We would like you to join us for our second Healthcare Safety Investigations Conference this September.
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Coronavirus

Report concludes review into intrapartum stillbirths during first wave of Covid-19

Our latest report sets out findings from our review into intrapartum stillbirths in the wake of the COVID-19 pandemic.
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HSIB publishes report focusing on themes from 22 national investigations

Our latest report charts an analysis of HSIB’s first 22 national investigations to identify recurring patient safety themes.
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New report highlights safety risk of delay in diagnosing spinal nerve compression condition

The importance of detecting a rare but life-changing spinal nerve condition called cauda equina syndrome (CES) is the focus of our latest national report.
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HSIB’s maternity programme: a year in review

Our latest report charts the progress of our maternity investigation programme over the last year and the influence of our work at a local and national level.
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Annual review reflects on progress and achievements during an unprecedented year

Our fourth annual review highlights the work we have done during 2020/21. Like many organisations we have had to adapt to the Covid-19 pandemic and have provided support and expertise to the healthca…
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Report concludes safety investigation into COVID-19 demands on oxygen delivery in hospitals

Oxygen pipeline issues during COVID-19 highlighted where crucial improvements to planning, system design and infrastructure could be made to ensure that hospitals can always meet oxygen flow needs, e…
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Follow up: webinar on management of chronic asthma management

HSIB held a webinar on 12 May to discuss asthma management in children, to support the launch of their recent publication: Management of chronic asthma in children aged 16 years and under.
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New report highlights fetal heart rate monitoring equipment issues in maternity care across NHS

Our latest national report focuses on the equipment used in maternity units across England to carry out continuous fetal heart rate monitoring during labour and birth.
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Follow-up: HSIB Ambulance Service Safety Learning Webinar

The Association of Ambulance Chief Executives (AACE) and HSIB held a safety learning webinar on 21 June 2021 specifically for ambulance services staff.
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Report concludes safety investigation into COVID-19 demands on oxygen delivery in hospitals.

Oxygen pipeline issues during COVID-19 highlighted where crucial improvements to planning, system design and infrastructure could be made to ensure that hospitals can always meet oxygen flow needs, e…
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WEBINAR INVITE: HSIB Ambulance Service Safety Learning Webinar

The Association of Ambulance Chief Executives and the Healthcare Safety Investigation Branch (HSIB) would like to invite you to a safety learning webinar which is aimed specifically for ambulance ser…
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HSIB release interim bulletin relating to wrong route medication investigation

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation on the wrong route administration of an oral drug into a vein.
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System needed to identify effectiveness of the measures intended to reduce patient safety incidents

HSIB’s latest report highlights a gap between the NHS and other safety-critical industries in identifying and managing barriers to reduce the risk of serious incidents occurring.
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New report highlights risk of outpatients receiving unintended ‘invasive procedures’

Our latest report says that a better system of safety measures is needed to make sure patients are not mixed up and given the wrong invasive procedure during outpatient appointments.
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Safety body examines ‘life-threatening’ risk of chronic asthma in children under 16

The difficulty in diagnosing and managing chronic childhood asthma is the focus of our latest report.
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New report shows patients could be ‘lost’ in follow-up appointment gap

Patients risk being 'lost' when follow-up appointments aren't booked after an inpatient stay, says HSIB’s latest national report.
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HSIB highlights ‘time-critical’ delay to heart attack treatment

Our latest national report says that patients suffering from a heart attack face ambulance delays that could impact their ability to have life-saving treatment.
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Safety body warns of ‘residual drug’ patient safety risk

Our latest national report shows that powerful anaesthetic drugs left behind in intravenous tubes pose a life-threatening risk to patients.
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New report examines impact of first wave of COVID-19 on maternal deaths

Our latest report offers crucial learning from maternal death investigations undertaken during the first peak of the COVID-19 pandemic.
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Report shines a light on ‘time-critical’ emergency associated with the birth of larger babies

Our latest maternity national report highlights that larger than average babies are at increased risk of nerve damage, brain injury or death when their shoulders get stuck during birth.
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Early findings from oxygen issues during COVID-19 pandemic investigation

We have been investigating piped oxygen gas supplies in hospitals and have produced an early interim bulletin to help trusts deal with oxygen flow issues in their organisations.
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HSIB recommends overhaul to NHS list to ensure ‘Never Events’ are truly never events

Our latest national report states that Never Events should not be defined as such if they don’t have strong enough barriers in place to stop them happening.
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HSIB investigates oxygen issues during the COVID-19 pandemic

We have today, 15 January 2021, launched a national investigation into the provision of piped oxygen gas supplies to hospitals.
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Support for NHS staff is crucial to improving patient safety

Our latest report outlines the most important factors for supporting staff in the wake of safety incidents, against the backdrop of the Covid-19 pandemic.
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HSIB highlights patient safety risks of nasogastric tube never events

Our latest report focuses on the life-threatening risk posed by the accidental misplacement of tubes that deliver food or medication to critically ill patients.
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New report highlights challenges of implementing ‘smart’ pump devices across NHS

Our latest report charts the emerging patient safety risks that can come with the introduction of ‘smart’ infusion pump technology into hospitals.
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National report highlights impact and suggests improvements to reduce the risk of delays to critical interventions during birth

Identifying improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell is the focus of our latest national investiga…
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National report charts challenges of managing COVID-19 transmission in hospitals

Helping the healthcare system reduce the spread of coronavirus (COVID-19) in hospitals is the focus of our latest national report.
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Recognising Baby Loss Awareness Week (9-15 October 2020)

Through our maternity investigations, we hear the devastating experiences from families who have lost a baby. We recognise the importance of Baby Loss Awareness Week and the work that is being done t…
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New report highlights missed opportunities in stroke aftercare

Crucial treatments missed in stroke aftercare could lead to fatal blood clots, highlights our latest national investigation report.
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HSIB highlights deadly impact of high-risk medication errors

Failure to identify high-risk medication errors in patients with complex needs can have a fatal outcome, our new report warns today.
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New report emphasises importance of the ‘family voice’ in healthcare investigations

In our latest report, we have outlined our unique approach to working with patients and families with the aim of sharing that learning across the healthcare sector.
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Join our online seminar to mark World Patient Safety Day

We would like to invite you to our 'Healthcare Safety Investigations Online Seminar & Learning Event' to mark World Patient Safety Day on 17 September 2020.
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New report highlights PPE guidance safety risk

Our latest national intelligence report reiterates the importance of clear PPE guidelines to reduce the risk of coronavirus (COVID-19) transmission when delivering care in people’s homes.
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Annual Review highlights progress and achievements in the last year

We are delighted to present our third Annual Review.
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New report confirms importance of clinical vigilance in the immediate postnatal period for safe care of babies

The latest maternity learning report from the Healthcare Safety Investigation Branch focuses on the importance of clinical monitoring to ensure that babies are as safe as possible during crucial skin…
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Behind the scenes: HSIB’s rapid approach to highlighting emerging COVID-19 patient safety risks

Since our inception, the Healthcare Safety Investigation Branch (HSIB) has sought to identify, analyse, and investigate some of the most common patient safety risks facing the NHS.
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HSIB working through the coronavirus pandemic and looking ahead

Since March 2020, we have been working closely with NHS trusts and national healthcare bodies to use our expertise in helping the fight against the coronavirus (COVID-19) pandemic.
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National report highlights life threatening risk posed by delay in group B strep treatment

Delay or failure to give preventative antibiotics to mothers can leave newborn babies at risk of death or severe injury from group B strep infection, our latest report shows.
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Simulation helps NHS prepare during coronavirus pandemic

The NHS is using simulation to help prepare and test staff and systems during the coronavirus (COVID-19) pandemic. This article collates some of the simulation resources available that are relevant t…
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DHSC publishes HSIB East Kent Hospitals maternity summary report

In January 2020 the Healthcare Safety Investigation Branch was asked by the Department of Health and Social Care to provide a summary report of all the investigations it had undertaken, up to that po…
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HSIB changes maternity investigation procedure, and halts national investigations and report publication

As a result of the current coronavirus (COVID-19) pandemic, the Healthcare Safety Investigation Branch (HSIB) is changing the way it approaches maternity and national investigations to minimise the i…
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HSIB publishes first national investigation report

The Healthcare Safety Investigation Branch (HSIB) has today published its first investigation report relating to a surgical never event.
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HSIB investigators to stop visiting trusts to help reduce spread of coronavirus

As part of our day to day work HSIB staff and investigators visit healthcare organisations up and down the country.
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New report highlights the ‘devastating impact’ of missed ectopic pregnancy

Prompt referral to early pregnancy services can make the difference between life and death in the diagnosis of ectopic pregnancies, our report highlights today.
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Influential health equality advocate Patrick Vernon OBE joins HSIB

Patrick Vernon OBE has joined HSIB to help establish and lead our Citizens’ Partnership.
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Report highlights ‘toxic’ risk of beta blocker to prevent overdose deaths

The toxicity of a commonly prescribed beta blocker needs better recognition across the NHS to prevent deaths from overdose, our new report warns today (6 February 2020).
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