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Lack of timely monitoring of patients with glaucoma [PDF]

Remove: Healthcare Safety Investigation Branch source - 08 January 2020

Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS.

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Lack of timely monitoring of patients with glaucoma [PDF]

Remove: Healthcare Safety Investigation Branch source - 06 January 2020

Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS.

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Assistant practitioners in the NHS in England [PDF]

Remove: Skills for Health source - 01 May 2015 - Publisher: Skills for Health

This report examines the use of Assistant Practitioners in the NHS in England, explores the benefits of their use and the barriers to their further implementation, and also identifies ways in which...

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Undetected button/coin cell battery ingestion in children [PDF]

Remove: Healthcare Safety Investigation Branch source - 25 June 2019

This investigation looks at the undetected ingestion of button/coin cell batteries in children.

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Identifying and reducing high-risk prescribing errors in hospital [PDF]

Remove: Healthcare Safety Investigation Branch source - 19 July 2019

Information from NHS England suggests that medicine prescribing errors in hospital occur in around 7% of all prescriptions issued.

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Management of VTE risk in patients following thrombolysis for an acute stroke [PDF]

Remove: Healthcare Safety Investigation Branch source - 08 May 2019

The HSIB was notified of a patient who suffered an pulmonary embolism while under the care of an acute stroke unit.

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Failures in communication or follow-up of unexpected significant radiological findings [PDF]

Remove: Healthcare Safety Investigation Branch source - 17 July 2019

X-rays are the most common radiological examination.

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Wrong patient details on blood sample [PDF]

Remove: Healthcare Safety Investigation Branch source - 23 September 2019

Wrong blood in tube (WBIT) incidents can occur when blood samples are taken from patients and are either miscollected (blood is taken from the wrong patient but labelled with the correct patient...

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Management of acute onset testicular pain [PDF]

Remove: Healthcare Safety Investigation Branch source - 09 September 2019

Testicular torsion is a condition where the testicle twists, cuts off the blood supply and results in significant pain.

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Undiagnosed cardiomyopathy in a young person with autism [PDF]

Remove: Healthcare Safety Investigation Branch source - 19 August 2019

Hospitals with the facility to conduct MRI scans under general anaesthetic for children undertake between 1.

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Undetected button/coin cell battery ingestion in children [PDF]

Remove: Healthcare Safety Investigation Branch source - 30 July 2019

This investigation looks at the undetected ingestion of button/coin cell batteries in children.

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Management of chronic health conditions in prisons [PDF]

Remove: Healthcare Safety Investigation Branch source - 09 October 2019

Each day around 120 prisoners with ongoing medication needs are moved between prisons.

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Recognising and responding to critically unwell patients [PDF]

Remove: Healthcare Safety Investigation Branch source - 20 May 2019

Problems in recognising and responding to deteriorating patients continues to be a major source of severe harm and preventable death in hospitals.

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Potential under-recognised risk of harm from the use of propranolol [PDF]

Remove: Healthcare Safety Investigation Branch source - 18 March 2019

The HSIB was notified of a patient who died following an overdose of propranolol.

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Inadvertent administration of an oral liquid medicine into a vein [PDF]

Remove: Healthcare Safety Investigation Branch source - 08 April 2019

This investigation emphasises that complex and fragmented medicine safety processes are putting patients across the country at risk.

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Implantation of wrong prostheses during joint replacement surgery [PDF]

Remove: Healthcare Safety Investigation Branch source - 18 June 2018

Our first complete investigation relates to the implantation of the wrong prostheses (artificial body parts) during joint replacement surgery — a surgical never event.

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Transition from child and adolescent mental health services to adult mental health services [PDF]

Remove: Healthcare Safety Investigation Branch source - 09 July 2018

We investigate how young people are supported in the transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) when they turn 18 years old.

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Administering a wrong site nerve block [PDF]

Remove: Healthcare Safety Investigation Branch source - 12 September 2018

This investigation seeks to identify opportunities and systemic remedies to reduce the risk of wrong site anaesthetic nerve blocks occurring.

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Transfer of critically ill adults [PDF]

Remove: Healthcare Safety Investigation Branch source - 23 January 2019

This investigation – the first we launched – looks at the transfer of critically ill adults.

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Insertion of an incorrect intraocular lens [PDF]

Remove: Healthcare Safety Investigation Branch source - 12 November 2018

Cataract removal and implantation of an artificial lens is the most common surgical procedure undertaken by the NHS.

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Provision of mental health care to patients presenting at the emergency department [PDF]

Remove: Healthcare Safety Investigation Branch source - 22 November 2018

In England, it is estimated that 5% of all hospital emergency department attendances are primarily due to mental ill-health.

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Design and safe use of portable oxygen systems [PDF]

Remove: Healthcare Safety Investigation Branch source - 28 November 2018

NHS Improvement issued a patient safety alert on medical devices in January 2018.

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Piped supply of medical air and oxygen [PDF]

Remove: Healthcare Safety Investigation Branch source - 26 February 2019

This investigation focuses on the design and implementation of patient safety alerts.

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The diagnosis of ectopic pregnancy [PDF]

Remove: Healthcare Safety Investigation Branch source - 07 November 2018

Following an initial investigation into the care of a patient who had a ruptured fallopian tube following a delay in diagnosis of an ectopic pregnancy, the Healthcare Safety Investigation Branch...

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Electronic prescribing and medicines administration systems and safe discharge [PDF]

Remove: Healthcare Safety Investigation Branch source - 24 October 2019

We’ve identified a significant safety risk posed by poorly implemented electronic prescribing and medicines administration (ePMA) systems.

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Recognising and responding to critically unwell patients [PDF]

Remove: Healthcare Safety Investigation Branch source - 28 June 2019

Problems in recognising and responding to deteriorating patients continues to be a major source of severe harm and preventable death in hospitals.

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Detection of retained vaginal swabs and tampons following childbirth [PDF]

Remove: Healthcare Safety Investigation Branch source - 09 December 2019

Women can be left in severe pain and at risk of infection if swabs and tampons used after childbirth are accidentally left in the vagina.

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Results for all evidence | Safety Alerts | Healthcare Safety Investigation Branch 1 - 27 of 27 sorted by relevance / date

Lack of timely monitoring of patients with glaucoma [PDF]

Lack of timely monitoring of patients with glaucoma [PDF]

Assistant practitioners in the NHS in England [PDF]

Undetected button/coin cell battery ingestion in children [PDF]

Identifying and reducing high-risk prescribing errors in hospital [PDF]

Management of VTE risk in patients following thrombolysis for an acute stroke [PDF]

Failures in communication or follow-up of unexpected significant radiological findings [PDF]

Wrong patient details on blood sample [PDF]

Management of acute onset testicular pain [PDF]

Undiagnosed cardiomyopathy in a young person with autism [PDF]

Undetected button/coin cell battery ingestion in children [PDF]

Management of chronic health conditions in prisons [PDF]

Recognising and responding to critically unwell patients [PDF]

Potential under-recognised risk of harm from the use of propranolol [PDF]

Inadvertent administration of an oral liquid medicine into a vein [PDF]

Implantation of wrong prostheses during joint replacement surgery [PDF]

Transition from child and adolescent mental health services to adult mental health services [PDF]

Administering a wrong site nerve block [PDF]

Transfer of critically ill adults [PDF]

Insertion of an incorrect intraocular lens [PDF]

Provision of mental health care to patients presenting at the emergency department [PDF]

Design and safe use of portable oxygen systems [PDF]

Piped supply of medical air and oxygen [PDF]

The diagnosis of ectopic pregnancy [PDF]

Electronic prescribing and medicines administration systems and safe discharge [PDF]

Recognising and responding to critically unwell patients [PDF]

Detection of retained vaginal swabs and tampons following childbirth [PDF]