Electronic Prescribing and Medicines Admin Systems and Safe Discharge

HSIB has identified a significant safety risk posed by the communication and transfer of information between secondary care, primary care and community pharmacy relating to medicines at the time of hospital discharge. A reference event was identified that resulted in...

HSIB Report wrong blood sample

HSIB’s latest report highlights that mislabelling of blood samples could pose a deadly risk to patients.The reference event in the report is a case where patient details became mixed up on blood samples sent from a maternity unit. In the case of mislabelling on...

The use of Human Factors to understand root causes Nikki Davey, CHFG Trustee

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. Further reading www.hsib.org.uk  ...

Patient Safety Strategy 2019

Following on from the consultation, Aiden Fowler launched the NHS Patient Safety Strategy and Patient Safety Congress last week.  There are 3 strategic aims:- Insight – improving understanding of safety by drawing on intelligence from multiple sources of patient...

HSIB report Recognising and responding to critically unwell patients

HSIB have written their latest investigation report which looks at the case of the deteriorating patient.  The national investigation explored the human factors which may influence recognition and response to a patient who is critically unwell.  It focused on:...

HSIB investigation report – wrong route medication error

HSIB have launched their latest investigation report in April 2019. The reference event A nine-year-old child was admitted to a hospital day case ward for an elective renal biopsy, which involves taking a small piece of kidney using a special needle. The procedure can...