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Report shows retention of learning disability nurses is vital for consistency of medication care

Our latest report highlights a shortage of learning disability nurses. The number joining the profession each year is matched by those leaving. We look at how this could impact on the care of patient…
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13 delegates from Ukom, with HSIB's Lesley Kay, Deinniol Owens and Keith Conradi

Knowledge exchange with Norway

In 2017 HSIB was the first organisation in the world set up to improve patient safety through independent investigations without blame.Now we’re not alone though, as Norway were hot on our heels with…
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An ambulance drives at speed past the houses of parliament in Westminster.

Interim report calls for immediate action to reduce harm to patients from handover delays

Delays in handing over care from ambulance crews to emergency departments is causing life-threatening harm to patients.
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Older male man lies on a bed with his worried wife sitting with him, holding his hand.

Zero avoidable deaths – an aspiration, not a target

Mel Ottewill, National Investigator and Senior Investigation Science Educator, shares her thoughts on the Investigation Education Team's seminar on 7 June 2022 where Jeremy Hunt MP was the guest…
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Rosie Benneyworth

Dr Rosie Benneyworth appointed interim Chief Investigator

We’re pleased to announce that Dr Rosie Benneyworth has been appointed as our new interim Chief Investigator for HSIB.
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Healthcare Safety Investigations Conference 2022

Our annual conference returns for its third year. Register for your free place now.
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A member of hospital staff from the sterile services department cleans surgical instruments, wearing scrubs, hair net, gloves and a mask.

New report focuses on regulation and governance to prevent the contamination of surgical instruments

The impact of ineffective decontamination of surgical instruments can be far-reaching. From the risk of severe infection, to the frustration of cancelled operations due to dirty equipment.
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HSIB welcomes Royal Assent of Health and Care Act

The Health and Care Act received Royal Assent yesterday (28 April 2022). This will establish the Health Services Safety Investigations Body (HSSIB) as a fully independent non-departmental public body…
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Healthcare Safety Investigation Branch Chief announces retirement

Keith Conradi, the Healthcare Safety Investigation Branch’s (HSIB) first Chief Investigator has announced his retirement.
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Older male man lies on a bed with his worried wife sitting with him, holding his hand.

Report examines unintentional overdose of powerful medication used for pain relief

We've published a short report that examines the specific risks which may be associated with morphine sulfate oral liquid in a community setting for acute pain.
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BAPM Webinar: Sudden Unexpected Postnatal Collapse

This free to attend webinar is being delivered by the British Association of Perinatal Medicine (BAPM) in partnership with HSIB.
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A Black mother cradles her newborn baby who is asleep in her arms.

Ockenden report

We are pleased that the Ockenden report strongly endorses the government’s plan to establish our maternity investigations programme as a Special Health Authority, to continue providing ‘independent, …
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An ambulance parked outside a hospital

Investigation highlights challenges when diagnosing ‘time-critical’ pulmonary embolism in the emergency department

Our latest report highlights the risk to patients from a pulmonary embolism (PE) being missed or not treated at the point they seek emergency care and focuses on learning to support clinical decision…
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The exterior front entrance of a hospital emergency department, with ambulances parked outside.

Report examines safety risk to stroke patients when transferred between trusts for emergency care

The third and final report from HSIB’s local integrated investigation pilot focuses on the co-ordination between two hospital trusts and an ambulance trust when dealing with the emergency care of a s…
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A sleeping newborn baby with brown hair wears an oxygen mask, with a plaster holding a tube in place on their face.

Report highlights risks of delays in emergency neonatal blood transfusions

Delays in emergency blood transfusions given during resuscitation can pose a risk to newborn babies, says our latest report.
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White capsule shaped pills marked with a dose of 500 spill out of a cup.

Report examines oral paracetamol toxicity in adults with low bodyweight

Adult inpatients with low bodyweight and the risk of liver toxicity from oral paracetamol is the focus of our latest national investigation report.
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A pregnant woman with short blonde hair stands in her living room with one hand on her bump, while making a phone call.

New report explores safety risks associated with maternity pre-arrival instructions by 999 call handlers

Our latest report highlights that maternity pre-arrival instructions from 999 call handlers could represent a ‘postcode lottery’ of care for women and pregnant people experiencing maternity emergenci…
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A doctor comforts a woman lying in a hospital bed.

Special Health Authority announced for independent maternity investigations

Plans to establish a Special Health Authority to continue the HSIB maternity investigation programme have been announced in Parliament (26 January, 2022) by Sajid Javid, Secretary of State for Health…
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A male doctor wearing a white coat injects medication into the arm of a young boy.

Report recommends safety regulation of technology systems to tackle weight-based medication errors

Regulation of electronic prescribing systems software could help to reduce the chance of harmful weight-based prescribing errors, says our latest report.
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Sharing learning for shared care

Dr Nick Woodier, HSIB National Investigator, reflects on the challenges associated with joint surgical care of patients and shares learning that can aid the NHS and the private sector as new national…
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A microscopic view of the coronavirus. They appear as blue spheres with spikes sticking out of them.

Learning from HSIB COVID-19 reports

Since the beginning of the coronavirus (COVID-19) pandemic we have worked to conduct investigations that help healthcare staff combat the virus.
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Embedding safety – reflecting on our button battery investigation

As Christmas approaches, Helen Jones National Investigator reflects on HSIB’s button battery investigation and updates on what happened after the high profile report was published.
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A member of care home staff walks around a garden with their arm around the shoulders of an older person.

Report examines case of incorrect patient details during handover of care between local healthcare organisations

The second report from our local integrated investigation pilot focuses on the impact of incorrect patient details during handover of care.
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Report highlights impact of delays in recognising acutely unwell infants

Recognising serious illness in infants and young children remains a key patient safety risk across the NHS, says our latest report.
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A doctor and investigator discussing a file in a hospital corridor.

HSIB publishes first local investigation pilot report focused on incorrect patient identification

The first report from HSIB’s local integrated investigation pilot has now been published.
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CPAP machine

Report examines COVID-19 breathing equipment safety risk

Our latest report shows that monitoring patients who need special equipment to support their breathing when they are not in a critical care unit is crucial to ensuring their safety.
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Report examines shared care of surgical patients between NHS and private hospitals

In our latest report, we show that successful collaborations between NHS hospitals and independent hospitals helps to protect patients when providing shared care.
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New report focuses on missed diagnosis of lung cancer

Our latest report explores the impact of the missed detection of lung cancer on chest X-rays of patients being seen in primary care.
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Healthcare Safety Investigations Conference 2021

Nearly 1,200 people joined us for our second annual Patient Safety Investigation Conference on 16 September 2021, making it our biggest yet.
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A microscopic view of the coronavirus. They appear as blue spheres with spikes sticking out of them.

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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A heart rhythm displayed on a monitor.

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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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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An ambulance drives at speed past the houses of parliament in Westminster.

Webinar: ambulance service safety learning

This webinar was held jointly by the Association of Ambulance Chief Executives (AACE) and HSIB for ambulance services staff.
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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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Fig 15 Example of workspace for prescribing medication and used for other administrative tasks

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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Webinar: asthma management in children

We held a webinar to mark the publication of our national investigation report looking at management of chronic asthma in children aged 16 years and under.
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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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An ambulance drives at speed past the houses of parliament in Westminster.

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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