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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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Earlier recognition of aortic dissection needed to prevent deaths

Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care, according to our new report.
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Latest HSIB report highlights ‘devastating’ impact of delays and pressure on national glaucoma services

Delays to follow-up appointments for glaucoma patients leaves them at risk of sight loss, warns our new report.
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New national investigation looks at implementation of safety improvements for the placement of NG tubes

We’ve launched an investigation looking at nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice.
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New national investigation looks at outpatient appointments after hospital stays

This investigation looks into a safety risks involving outpatient follow-up appointments which are intended but not booked after hospital stays.
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New Advisory Panel Chair announced

The Healthcare Safety Investigation Branch (HSIB) is pleased to announce the appointment of Murray Anderson-Wallace as its new Advisory Panel Chair.
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Report highlights common ‘never event’ that leaves women at risk of harm after childbirth

Women can be left in severe pain and at risk of infection if swabs and tampons used after childbirth are accidentally left in the vagina.
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Annual Review reflects on progress and achievements in the last year

As the new year approaches it’s an appropriate time to reflect on HSIB’s progress and achievements during 2018/19, with the publication of our Annual Review.
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Health Service Safety Investigations Bill receives second reading in House of Lords

The Government’s Bill to establish an independent non-departmental public body has received its second reading in the House of Lords.
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HSIB Position Statement - CQC State of Care 2018/19

Responding to the publication of the Care Quality Commission’s State of Care 2018/19, Keith Conradi, Chief Investigator for the HSIB said:
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HSSIB Bill has first reading in House of Lords

We have started our journey to becoming an arm’s-length body after our Bill was mentioned in the Queen’s Speech on 14 October 2019.
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‘HSSIB’ Bill announced in Queen’s speech

A Bill to fully establish the Healthcare Safety Investigation Branch (HSIB) as an arm’s-length body has been one of 26 proposed bills announced in the Queen’s speech at the State Opening of Parliamen…
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Highlighting the stories behind our investigations on World Mental Health Day

Today HSIB supports World Mental Health Day, highlighting the stories behind two of our national investigations and the improvements being made to mental health care across the NHS.
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HSIB highlights impact of blood sampling errors across NHS

The Government’s Bill to establish an independent non-departmental public body has received its second reading in the House of Lords (29 October 2019).
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Investigation into insulin prescribing in hospitals starts

We’ve started a national investigation looking into insulin prescribing and administration in hospitals.
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How HSIB marked the first World Patient Safety Day

Our organisation is the first in the world to investigate patient safety concerns nationally.
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HSIB highlights its contribution on the eve of World Patient Safety Day

Tomorrow (17 September), HSIB celebrates the first-ever World Patient Safety Day. This is a global initiative established by the World Health Organization (WHO) to create awareness of patient safety …
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National bodies respond to safety recommendations in critically unwell patients report

We made safety recommendations to The Royal College of Physicians and NHS England/NHS Improvement as a result of our investigation into recognising and responding to critically unwell patients.
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Latest HSIB report focuses on speedier diagnosis of time-critical testicular torsion

A report published today (12 September ) sets out a number of safety recommendations to improve the diagnosis and treatment of testicular torsion, a time critical-condition that mainly affects young …
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HSIB marks first World Patient Safety Day

Along with many healthcare organisations across the globe, we are celebrating the first ever World Patient Safety Day on 17 September and highlighting the work we do to improve patient safety across …
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Gap in care for chronically ill prisoners

Prisoners are at risk of being transferred without crucial medication, according to our latest healthcare safety investigation report.
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New investigation looks at the procurement, usability and adoption of ‘smart’ pumps

HSIB have launched an investigation after being notified of three incidents where an accidental fentanyl overdose occurred. The Trust had administered the powerful pain medication using a ‘smart’ inf…
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Bulletin on progress in our high-risk prescribing errors investigation is released

The Healthcare Safety Investigation Branch (HSIB) has published an interim bulletin for its investigation looking at identifying and reducing high-risk prescribing errors in hospital.
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Latest HSIB report focuses on technology to reduce risk of X-ray findings getting lost

A report published today (18 July) by HSIB showcases where technology could play a pivotal role in reducing harm caused by failures in communication or follow-up of unexpected significant radiologica…
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New investigation looks at delayed recognition of retained vaginal swabs and tampons following childbirth

HSIB has launched an investigation into the delayed recognition of retained vaginal swabs and tampons following childbirth.
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Interim bulletin released relating to the lack of timely monitoring of patients with glaucoma

We have released an interim bulletin relating to the lack of timely monitoring of patients with glaucoma.
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HSIB issues recommendations to prevent ‘devastating’ deaths from button/coin cell batteries

In our latest report (published 27 June) we have put forward a number of safety recommendations to prevent serious injuries or death from the unknown ingestion of button/coin cell batteries.
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National Patient Safety Alert Committee responds to HSIB safety recommendation

We made a safety recommendation to the National Patient Safety Alert Committee as a result of our investigation into the piped supply of medical air and oxygen.
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Notification of investigation: wrong patient details on blood sample

The HSIB was notified of an incident where a patient’s blood sample was incorrectly labelled with another patient’s details. HSIB has launched an investigation regarding incorrect patient details bei…
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Notification of investigation: undiagnosed cardiomyopathy in a young person with a learning disability

The HSIB was notified of an incident where a young patient with undiagnosed cardiomyopathy died following an anaesthetic which was needed to facilitate a Magnetic Resonance Imaging (MRI) scan. The pa…
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Dr Stephen Drage joins HSIB as director of investigations

We’ve appointed a new director of investigations to lead the continued delivery of our national investigations programme.
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Notification of investigation: lack of timely monitoring for patients with glaucoma

The HSIB was made aware of a woman who was referred to hospital eye services for urgent assessment of glaucoma.
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Interim bulletin released relating to the management of VTE risk in patients following thrombolysis for an acute stroke

We have released an interim bulletin relating to the management of Venous Thromboembolism (VTE) risk in patients following thrombolysis for an acute stroke.
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HSIB’s family engagement approach nominated for prestigious patient safety award

Our innovative model of family engagement has been nominated in the ‘best emerging solution for patient safety’ category at the 2019 HSJ Patient Safety Awards.
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HSIB investigation tackles national complexity of medicine safety

Our latest report published 11 April 2019, emphasises that complex and fragmented medicine safety processes are putting patients across the country at risk.
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Interim bulletin released relating to the potential under-recognised risk of harm from the use of propranolol

We have released an interim bulletin relating to the potential under-recognised risk of harm from the use of propranolol. Interim bulletins are released to share further details of each investigation…
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Notification of investigation: recognition of the acutely ill infant

The HSIB was notified of a three-month-old infant who was admitted in to a hospital and discharged four hours later. The infant was re-admitted less than four hours later and sadly died of Meningococ…
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HSIB’s maternity investigation programme completes rollout into 130 NHS trusts

From today, all trusts in England will be referring maternity cases to HSIB.From 1 April 2018, we became responsible for the investigations of maternity incidents that met the criteria for the Each B…
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New report focuses on design and implementation of patient safety alerts

Our latest report, published 28 February 2019, highlights that despite ongoing work, NHS trusts may face barriers when responding to national patient safety alerts.
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Notification of investigation: potential under-recognised risk of harm from the use of propranolol

The HSIB was notified of a patient who died following an overdose of propranolol.
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Notification of investigation: management of VTE risk in patients following thrombolysis for an acute stroke

The HSIB was notified of a patient who suffered an pulmonary embolism while under the care of an acute stroke unit.
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HSIB’s innovative approach ensures families are central to safety investigations

Both national and maternity investigations are showing a high level of family engagement through an inclusive and innovative model that ensures families have a voice throughout investigations.
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New report focuses on recommendations to make ambulance transfers safer

Our new report, published 24 January 2019, shows that a lack of national guidance and standard practice for ambulance transfers could be putting patients at risk.
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HSIB release interim bulletin relating to the management of chronic health conditions in prisons

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to the management of chronic health conditions in prisons.
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Electronic prescribing and medicines administration systems interim bulletin released

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to the investigation into electronic prescribing and medicines administration systems and safe discharge.
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Beware of button batteries this Christmas

We are calling for vigilance to the dangers of button batteries to children this Christmas. Parents and families should be aware of the potential harmful effects of button batteries if swallowed.
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Notification of investigation: piped supply of medical air and oxygen

The Healthcare Safety Investigation (HSIB) has launched a new investigation after an incident where a patient was connected to the medical air supply instead of the oxygen supply.
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HSIB report calls for better regulation of medical devices

Our new report published today has highlighted the high patient risk – with even possible risk of death - associated with some medical devices used within the NHS for patient care and treatment.
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HSIB national report reinforces need for 24/7 emergency mental health care

The Healthcare Safety Investigation Branch (HSIB) has today published its latest report highlighting the variation in mental health care across emergency departments and setting out four recommendati…
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