The use of Human Factors to understand root causes
Nikki Davey, Clinical Human Factors Group Trustee, talks about the work of Healthcare Safety Investigation Branch (HSIB) and the use of human factors and ergonomics.
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HSIB investigation report – wrong route medication error
HSIB have launched their latest investigation report in April 2019. The reference event A...
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HSIB investigation Report
HSIB have launched their latest report and recommendations into the piped supply of medical air...
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HSIB report on the transfer of critically ill adults
The Healthcare Safety Investigation Branch has launched its latest report regarding the transfer...
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New government Patient Safety Strategy Consultation
The Secretary of State for Health and Social Care recently launched the NHS 10-year plan....
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Opening the door to change – CQC report on Never Events
The Secretary of State for Health and Social Care asked the CQC to work with NHS Improvement to...
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Joint Committee published report on Health Service Safety Investigations Bill
The House of Lords and House of Commons created a Joint Select Committee to review the draft Health Service Safety Investigations Bill…
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HSIB Investigation report – transition from child mental health services to adult
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.
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HSIB first national investigation report – wrong prosthesis
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.
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