Patient safety investigations

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Older person in bed at home holding a mug and speaking with a carer seated beside the bed, with a bedside lamp and wooden headboard in the background.

Safety accountability and oversight thematic review

We have launched a thematic review of HSIB and HSSIB investigation reports, covering the period April 2017 to April 2026, that explores patient safety accountability and oversight.
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Launched

  • Theme:

    Long-term conditions, Patient safety themes, Continuity of care
Close up of hands using a smart phone.

Online prescribing: challenges and opportunities to improve patient safety

published
This investigation looks at the complex regulatory landscape around independent online prescribing and challenges sharing patient information between the NHS and independent online prescribing services.
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Published

  • Theme:

    Medication

  • Awaiting safety recommendation responses

A stylised illustration of a healthcare pathway made up of connected circular icons in blue and green. The icons include a heart monitor, stethoscope, ambulance, pills, syringe, DNA strand, test tube and medical cross, all linked by a flowing line to represent joined-up care.

Patient safety across regional care pathways: learning from an HSSIB investigation pilot

published
We've identified patient safety risks across regional care pathways, linked to unclear roles, limited oversight and inconsistent information sharing which can limit how risks are identified and managed across NHS organisations.
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Published

  • Theme:

    Communication and decision making, Access to care, Continuity of care
A female nurse gives an older woman medical pills.

Medication related harm

published
Medication is the most common intervention for patients in the NHS. In the most serious cases, delayed and missed medication can cause catastrophic effects. We have completed three local investigations and a national investigation that look at medication related harm.
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Published

  • Theme:

    Medication, Communication and decision making, Continuity of care

  • Awaiting safety recommendation responses

Aerial view of a prison site in the English countryside.

Healthcare provision in prisons

published
We've analysed the patient safety issues frequently highlighted within prison healthcare to identify themes. Our four investigation reports in this series span emergency care response, continuity of care, data sharing and IT, and needs assessments and disability access.
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Published

  • Theme:

    Emergency care, Communication and decision making, Continuity of care

  • Safety recommendation responses received

A healthcare assistant wearing blue scrubs checks the blood sugar level of a male patient.

Insulin: supporting safe administration in inpatient settings

published
This investigation examines risks to safety when patients who take insulin are admitted to acute hospitals. Insulin is a high risk medication and remains one of the most common causes of harm from medication errors in the NHS.
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Published

  • Theme:

    Medication, Long-term conditions, Hospital care

  • Safety recommendation responses received

Hands type on a laptop keyboard. Nine exclamation marks are superimposed over the photo, including one in a warning triangle, to signify an issue with the computer system.

Electronic patient record systems – risk from loss of functionality

We have launched an investigation that explores risks to patient safety where access to, the use of, or functionality of electronic patient record (EPR) systems has been lost. That loss may be short- or long-term, and be planned or unplanned.
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Launched

  • Theme:

    Communication and decision making, Medical tests, Continuity of care
A male nurse kneels next to a female patient laying in a bed on a hospital corridor.

Patient care in temporary care environments

published
This investigation explores the management of patient safety risks associated with using temporary care environments, often referred to as ‘corridor care’ and ‘temporary escalation spaces’.
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Published

  • Theme:

    Acute, Emergency care, Patient safety themes
A man in scrubs intently using a tablet computer in a clinical setting.

Electronic patient record (EPR) systems – thematic review

published
This thematic review of 50 HSSIB reports identifies specific patient safety issues and learning related to EPR systems. The report includes a safety observation and local-level learning prompts around safe selection and procurement, implementation and ongoing optimisation of EPR systems.
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Published

  • Theme:

    NHS staff, Communication and decision making, Medical devices
Close-up of man with a closely trimmed beard. He takes a pill with a glass of water.

The use of lithium for bipolar disorder

Around 1 in 50 adults experience bipolar disorder within their lives. Whilst the number of people with bipolar disorder has remained consistent over time the prescribing of lithium has been in decline for decades.
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Launched

  • Theme:

    Mental health, Medication
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