Our latest publications, with links to download the full report including safety recommendations, the associated press release and key press coverage.

For more information about our journey to become an independent non-departmental public body see the HSSIB Bill page.

For previous publications, please see the press office archive page.

Placement of nasogastric tubes

National report published 17 December 2020.

This investigation looked at nasogastric (NG) tubes and how previously identified safety improvements for the placement of these tubes are put into practice. Data from national reporting systems shows that there were 14 incidents of misplaced NG tubes from April to September this year.

Press release: New report highlights patient safety risks of nasogastric tube never events

Final report: Placement of nasogastric tubes

Procurement, usability and adoption of ‘smart’ infusion pumps

National report published 3 December 2020.

We have looked at the challenges of introducing ‘smart’ infusion pumps in NHS hospitals. Although the aim of smart infusion pumps is to improve patient safety, the technology can introduce new risks.

Press release: Safety body highlights challenges of implementing ‘smart’ pump devices across NHS

Final report: procurement, usability and adoption of ‘smart’ infusion pumps

Delays to intrapartum intervention once fetal compromise is suspected

National report published 12 November 2020.

We have identified a safety risk in maternity care relating to delays to intrapartum intervention once fetal compromise is suspected. Our review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to these delays.

Press release: National report highlights impact and suggests improvements to reduce the risk of delays to critical interventions during birth

Final report: Delays to intrapartum intervention once fetal compromise is suspected

COVID-19 transmission in hospitals: management of the risk

National report published 29 October 2020.

Helping the healthcare system reduce the spread of coronavirus (COVID-19) in hospitals is the focus of this report. It charts a four-month patient safety investigation that was launched following concern that patients were contracting COVID-19 after being admitted to hospital.

Press release: national report charts challenges of managing COVID-19 transmission in hospitals (PDF)

Final report: COVID-19 transmission in hospitals

Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke

National report published 13 October 2020.

Strokes are the fourth most common cause of death in the UK and around one in ten people die before they reach hospital. This report emphasises that if patients do survive, then the assessment of care in wards and units is key to prevent any further risk to life.

Press release: new report highlights missed opportunities in stroke aftercare (PDF)

Final report: Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke

The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital

National report published 24 September 2020.

This healthcare safety investigation looks at errors when prescribing high-risk medications to older patients in hospitals with multiple medical problems.

Press release: safety body highlights deadly impact of high-risk medication errors (PDF)

Final report: The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital

Previous publications

For previous publications see the press office archive.