New investigation looks at the procurement, usability and adoption of ‘smart’ pumps
- By: Communications team
- Posted on: 21 Aug 2019
We launched this investigation after we were notified of three incidents where an accidental fentanyl overdose occurred. The Trust had administered the powerful pain medication using a smart pump.
Update on our investigation looking at undiagnosed cardiomyopathy in a young person with autism
- By: Communications team
- Posted on: 20 Aug 2019
We’re working with stakeholders to develop safety recommendations to support clinicians to effectively communicate with, and assess, patients to optimise the chances of detecting diseases, some of which may be more prevalent in those with autism or learning disabilities.
Online feedback form launched so you can ‘tell us what you think’
- By: Communications team
- Posted on: 1 Aug 2019
We’ve just launched a new online feedback form so that anyone involved or interested in our healthcare safety investigations can tell us what they think. All the comments we receive are reviewed by our team and help us to improve our healthcare safety investigations.
Bulletin on progress in our high-risk prescribing errors investigation is released
- By: Communications team
- Posted on: 22 Jul 2019
The initial investigation considered that there may be a specific risk related to the administration of high-risk medicines to frail, elderly patients in hospital. Further investigation has identified specific risks associated with medication prescription and that these risks are not limited to the prescription of high-risk medications in isolation.
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 of 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.