Healthcare Safety Investigation Branch Reports
The Healthcare Safety Investigation Branch (HSIB) conducts independent investigations of patient safety concerns in NHS-funded care across England. HSIB aims to improve safety through effective and independent investigations that don't apportion blame or liability. Investigations identify the contributory factors that have led to harm or have the potential to cause harm to patients. The recommendations aim to improve healthcare systems and processes in order to reduce risk and improve safety.
- Placement of nasogastric tubes, summary (HSIB, Dec 2020)
- Placement of nasogastric tubes, full report (HSIB, Dec 2020)
- Procurement, usability and adoption of ‘smart’ infusion pumps , full report (HSIB, Dec 2020)
- Procurement, usability and adoption of ‘smart’ infusion pumps, summary (HSIB, Dec 2020)
- Delays to intrapartum intervention once fetal compromise is suspected, full report (HSIB, Nov 2020)
- Delays to intrapartum intervention once fetal compromise is suspected, Summary (HSIB, Nov 2020)
- Early warning scores to detect deterioration in Covid-19 inpatients (HSIB, Jul 2020)
- Investigation into electronic prescribing and medicines administration systems and safe discharge (HSIB, Oct 2019)
- Wrong patient details on blood sample, full report (HSIB, 2019)
- Wrong patient details on blood sample, summary (HSIB, 2019)
- Management of acute onset testicular pain (HSIB, Sept 2019)
- Failures in communication or follow-up of unexpected significant radiological findings (HSIB, Jul 2019)
- Undetected button/coin cell battery ingestion in children (HSIB, June 2019)
- Recognising and responding to critically unwell patients (HSIB, May 2019)
- Provision of mental health care to patients presenting at the emergency department (HSIB, Nov 2018)
The Francis Report is essential reading for all clinicians working in Emergency Departments and has important recommendations for patient safety. The Safer Care team have developed the following resources to support safety in the wake of the Francis review.
Francis report: a call to arms
The Francis Report is mandatory reading for all clinicians working in Emergency Departments. Drs Ruth Brown and Sue Robinson have written ‘The Francis Report: a call to arms,’ published within the Emergency Medicine Journal. In this article they advocate that the Francis report serves as a call to arms for ED staff to stop normalising the abnormal and tolerating substandard care, to respect and protect our patients and hold our leaders, and ourselves, to account.
You can view this document here.
Francis Report Recommendations – a Checklist for Senior Teams in Emergency Departments
The Francis report has many recommendations for organisations as a result of the enquiry. The College has developed this checklist for Clinical Directors of the Emergency Department – taking the most relevant recommendations and identifying key actions for clinical leaders of emergency departments. While the list is not exhaustive it is meant as a handy guide to action that might usefully be taken in the first instance. Download this document here.
Francis Report - Statement for Fellows and Members
The College has prepared a statement for Fellows and Members on the Francis Inquiry Report outlining what the report is and why it is important for Emergency Medicine. This document also acts a guide to challenging occurrences of poor care. This document can be found here.
The Berwick report is essential reading for emergency medicine practitioners. It identifies changes that could help the English NHS become safer and more patient-centered whilst making numerous recommendations to help protect patients.
Read the recommendations from Professor Don Berwick and the National Advisory Group on the Safety of Patients in England here.
Non-technical skills (NTS) have a vital role to play in Emergency Medicine practice. There is increasing awareness that a clinician must not only possess good technical skills but should also be proficient in a variety of interpersonal and cognitive skills in order to optimise patient care. Non-technical skills reduce the opportunity for human error and enhance risk management both of which are known to improve patient care. The College has prepared a Non-technical Skills-Top 10 Tips as a guide on how to maximise emergency physician’s non-technical skills for the benefit of patients and staff. Download this document here.