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A patient safety alert has been issued today (6 February 2014) by NHS England on the risk of hypothermia for patients on continuous renal replacement therapy (CRRT). This alert has been disseminated via the Central Alerting System (CAS) to ensure NHS staff are aware that it is never safe to use CRRT equipment without a fluid warmer, even for short periods. The alert was issued in response to three recent incidents; two patients became severely hypothermic and one of these patients has since died.
Dr Mike Durkin, National Director of Patient Safety, NHS England, said: “Patient safety alerts are a crucial part of our work to rapidly alert the healthcare system to risks and to provide guidance on preventing potential incidents that may lead to harm or death. These incidents are identified using our reporting system to spot emerging patterns at a national level, so that appropriate guidance can be developed and issued to protect patients from harm.”