• The Healthcare Safety Investigation Branch (HSIB) has published its first investigation report and safety recommendations.
• It follows an investigation after an incident where a 62-year-old man had two incompatible prostheses implanted during a total hip replacement.
• The report makes a number of safety recommendations aimed at NHS Improvement, the Department of Health and Social Care and other national bodies.

HSIB's investigation centred on how the error occurred and what recommendations could be made to reduce the risk of a similar event happening again.

Responding to the first investigation report by the Healthcare Safety Investigation Branch (HSIB), the head of policy at NHS Providers, Amber Jabbal, said:

“Safety must always be the first priority for the NHS.

“The first full report by the independent HSIB takes a new and positive approach to identifying why harm can happen in healthcare.

The first full report by the independent HSIB takes a new and positive approach to identifying why harm can happen in healthcare.

Amber Jabbal    

“By talking to patients and clinicians, as well as investigating good practice in other health systems, the HSIB offers an invaluable evidence-based perspective on how to reduce the risk of errors during hospital surgical procedures.

“These recommendations are an opportunity to drive system-wide safety improvement, reducing the risk of harm in the future, and offer valuable learning for providers and national bodies.

“The national bodies, to whom these recommendations are directed, must provide trusts with the appropriate resources and support to implement changes where needed.”