The Healthcare Safety Investigation Branch (HSIB) has released two interim bulletins charting the progress of investigations focusing on patient safety within an acute care setting.
The first investigation relates to a wrong site block given to a patient prior to ankle surgery. An initial investigation highlighted the wider issues around wrong site interventions, especially the checking processes throughout the patient pathway.The full investigation is focused on the design, implementation and monitoring of safety standards and initiatives within theatres.
The second investigation relates to a patient who deteriorated and died within 24 hours of presenting at hospital. The initial investigation highlighted the difficulties in recognising and responding to critically unwell patients. The full investigation is now focusing on the contextual, organisational and human factors involved in determining the severity of a patient’s condition and how that influences treatment.
Interim bulletins are released to share further details of each investigation,
including how it’s met HSIB criteria, the history of the event it relates to,
the national context and any identified safety issues.
The HSIB launched its first full investigation in July this year, and is now
carrying out seven full investigations.