This investigation followed the Healthcare Safety Investigation Branch being notified of an 18-year-old who died by suicide shortly after transitioning from child and adolescent to adult mental health services. The investigation identified possible issues regarding the transition process.
The Healthcare Safety Investigation Branch (HSIB) has published its first investigation report relating to a surgical never event.
The patient is a 63-year-old man who underwent hip replacement surgery. During this surgery, incompatible components were used. The error was identified when data from the procedure was recorded in the National Joint Registry.
The draft bill proposes setting up the Health Service Safety Investigations Body (HSSIB). The HSSIB will conduct investigations which focus on learning from patient safety incidents in the NHS, to reduce health care harm and improve patient care.
The Never Events policy and framework sets out the NHS’s policy on Never Events. It explains what they are and how staff providing and commissioning NHS-funded services should identify, investigate and manage the response to them. It is relevant to all NHS-funded care…
This thought paper explores how healthcare systems can develop a system-wide approach to investigating and learning from the most serious patient safety issues, and examines the organisational infrastructure that is needed to support this.