Understanding our reports

Our investigations focus on ways we can prevent patient safety incidents happening across the NHS, and fall under 22 broad themes, which we’ve listed here.

Healthcare setting

Emergency and triage. Investigations involving accident and emergency departments, urgent care centres, NHS 111 and 999, the ambulance service, and urgent referrals from General Practice (GP).

Follow-up care. Investigations into the need for further healthcare provision to manage known health conditions and when new conditions are identified after medical tests.

Home care. Investigations into the way NHS healthcare professionals deliver care when visiting patients at home.

Hospital care. Investigations into the care of patients who stay one or more nights in an NHS funded hospitals.

Long-term conditions. Investigations into the care of patients who require multiple points of contact with the healthcare system to manage long-term (or chronic) conditions.

Maternity. Investigations into aspects of NHS care during pregnancy, birth, and postnatal periods.

Medical technology. Investigations into the patient safety issues associated with medical devices, equipment, and information technology.

Medical tests. Investigations into patient safety issues associated with medical tests.

Medication. Investigations into how medication is prescribed, administered to patients, and monitored.

Mental healthcare. Investigations into mental healthcare provided by the NHS across different settings.

NHS staff. Reports that are focussed on NHS healthcare professionals.

Outpatient care. Investigations involving care of patients who attend a hospital to receive NHS treatment but are not required to stay overnight.

Patient and family. Reports that are focused on the involvement of patients and family.

Primary care. Investigations into the first point of contact in the healthcare system including GP, pharmacy, dentist, optician services.

Surgical. Investigations into surgical procedures as part of NHS care.

Analysis themes (second theme)

Access to care. If services are available, then the opportunity to obtain healthcare exists. However, barriers also exist, and these can prevent appropriate access to care and can cause problems during transitions of care (i.e., when changing care providers).

Checking. Many routine activities require healthcare workers to check that the intended treatment is being delivered correctly at the point of care. Good design includes the engineering of devices and equipment, the development of ways of working to minimise the likelihood of error, and effective training and education.

Communication and decision making. The delivery of healthcare is dependent on timely communication and effective decision making. There are many situations where pressures on the healthcare system can impact on the reliability of communication and decision making processes.