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.
Notification of investigation: lack of timely monitoring for patients with glaucoma
- By: Communications team
- Posted on: 10 May 2019
The HSIB was made aware of a woman who was referred to hospital eye services for urgent assessment of glaucoma. Due to a lack of capacity, there was a delay in the patient’s first appointment and her subsequent appointments over the course of 13 months. After a preliminary investigation with the full cooperation of local care providers, HSIB has decided to launch a full investigation.
Interim bulletin released relating to the management of VTE risk in patients following thrombolysis for an acute stroke
- By: Communications team
- Posted on: 8 May 2019
If a patient has suffered an acute stroke, they are at increased risk of developing deep vein thrombosis due to immobility, which may result in a pulmonary embolism. HSIB identified the management of Venous Thromboembolism for patients that have suffered an ischaemic stroke and received thrombolysis as a significant patient safety risk.
HSIB’s family engagement approach nominated for prestigious patient safety award
- By: Communications team
- Posted on: 15 Apr 2019
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.
HSIB investigation tackles national complexity of medicine safety
- By: Communications team
- Posted on: 11 Apr 2019
Our latest report emphasises that complex and fragmented medicine safety processes are putting patients across the country at risk. The report puts forward a number of recommendations aimed at driving national improvement to reduce potentially fatal medication errors.
Interim bulletin released relating to the potential under-recognised risk of harm from the use of propranolol
- By: Communications team
- Posted on: 28 Mar 2019
When taken in large quantities, propranolol can act rapidly to significantly decrease the heart rate and blood pressure whilst simultaneously impacting on the body’s ability to process sodium, leading to seizures, confusion or coma.
Notification of investigation: recognition of the acutely ill infant
- By: Communications team
- Posted on: 20 Mar 2019
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 Meningococcus (serogroup B). HSIB has launched an investigation regarding the recognition of the acutely ill infant.