Latest HSIB report focuses on technology to reduce risk of X-ray findings getting lost
- By: Communications team
- Posted on: 18 Jul 2019
The lack of follow-up or communication of unexpected significant findings can have a serious or life-threatening impact on patients. This was seen in the reference case that informed this investigation. In that event, a 76-year old woman had a chest X-ray showing a possible lung cancer which was not followed up and resulted in a delayed diagnosis. The patient died just over two months after her diagnosis.
New investigation looks at delayed recognition of retained vaginal swabs and tampons following childbirth
- By: Communications team
- Posted on: 11 Jul 2019
The investigation will focus on the on use and detectability of swabs and tampons and will explore the environmental and team factors that surrounded the incident.
Interim bulletin released relating to the lack of timely monitoring to patients with glaucoma
- By: Communications team
- Posted on: 4 Jul 2019
We have released an interim bulletin relating to the lack of timely monitoring of patients with glaucoma.
Prestigious awards celebrate continued drive to improve patient outcomes
- By: Communications team
- Posted on: 3 Jul 2019
Representatives from HSIB attended a prestigious awards ceremony in Manchester yesterday evening (2 July 2019) to celebrate the organisations who continue to drive improved patient outcomes across the UK.
HSIB issues recommendations to prevent ‘devastating’ deaths from button/coin cell batteries
- By: Communications team
- Posted on: 27 Jun 2019
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.
National Patient Safety Alert Committee responds to HSIB safety recommendation
- By: Communications team
- Posted on: 10 Jun 2019
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. The National Patient Safety Alert Committee has now introduced a set of standards – agreed in 2018 – for National Patient Safety Alerts.
HSIB report reinforces national approach to tackle preventable deaths from deterioration
- By: Communications team
- Posted on: 23 May 2019
Our latest report recommends tackling the recognition and response to deteriorating patients with the same national approach driving improvement in identifying and treating sepsis. As a result we’ve made safety recommendations to The Royal College of Physicians and NHS England/NHS Improvement.
Notification of investigation: wrong patient details on blood sample
- By: Communications team
- Posted on: 16 May 2019
The investigation will focus on providing a Safety II approach to consider staff perspectives on blood sampling and labelling practice. Safety II considers how performance is adapted to respond to varying conditions and how these adaptations represent not only how things go wrong, but also how things usually go right.
Notification of investigation: undiagnosed cardiomyopathy in a young person with a learning disability
- By: Communications team
- Posted on: 15 May 2019
HSIB has launched a national investigation regarding the pre-assessment of children who need to undergo planned general anaesthetics and the potential impact of learning disabilities on these processes. Additionally, the investigation will explore the challenges of providing general anaesthesia for MRI scans.
Dr Stephen Drage joins HSIB as director of investigations
- By: Communications team
- Posted on: 13 May 2019
We’ve appointed a new director of investigations to lead the continued delivery of our national investigations programme. Dr Stephen Drage joins us from Brighton and Sussex University Hospitals NHS Trust, where he held the position of deputy medical director for six years.