We investigate patient safety concerns across England to improve NHS care at a national level.
We aim to be the global leader in professional, high quality healthcare safety investigations. We investigate patient safety concerns across England to improve NHS care at a national level. Our investigations do not find blame or liability with individuals or organisations. Information shared with us is confidential and protected by law.
We are a fully independent arm’s length body of the Department of Health and Social Care.
We can investigate patient safety concerns that occur in England during the provision of healthcare services, and that have or may have implications for the safety of patients.
Our investigations can consider healthcare provided in the NHS and the independent sector. Where an investigation relates to an incident that did not occur in the NHS, we must consider whether NHS systems and practices could be improved because of our investigation.
We can also be directed to investigate a patient safety concern by the Secretary of State for Health and Social Care.
We offer an education programme to the NHS in England delivered by professional healthcare safety investigation experts.
Our courses are aimed at NHS staff in health and social care settings in England, who are involved in safety investigations for learning. We offer a range of courses and standalone sessions to support development and help embed professional safety investigations across the NHS.
Courses run online and are free of charge to attend for NHS staff in England.
Retained swabs are classed as Never Events. Data shows there has been 11-23 retained swab incidents per year since 2015. The investigation was launched after we examined the case of a patient who had two swabs left in her chest following serious heart surgery.
From analysis of 30 NHS serious incident reports, we found 18 cases where temporary staff were not involved in subsequent patient safety investigations. This is the first report published as part of our workforce and patient safety theme.
Patient misidentification was highlighted as a risk to patient safety by the National Patient Safety Agency in the early 2000s. Despite the time that has passed, patient misidentification remains a persistent risk to patient safety that can result in significant harm.
We would like to hear from everyone, including patients, families and NHS and healthcare staff.
Share a concern