Through its core work to review patients safety events recorded on national systems such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified an issue with oxygen hoses becoming disconnected from transport ventilators. An issue raised in a […]
NHS England today welcomes the Berwick Report into NHS patient safety, and pledges further action to help make the NHS the safest healthcare system in the world. Professor Don Berwick, renowned international expert in patient safety, was asked by the Prime Minister to carry out the review following the publication of the Francis Report into […]
Since the publication of this blog Dr Mike Durkin has left NHS England. By Dr Mike Durkin, NHS England director of patient safety: Patient safety has been a key priority in NHS England’s first year. There can be no question that it should always be of paramount importance to everyone working in the NHS, but […]
A new alerting system launched today by NHS England will ensure warnings of potential risks to the safety of patients can be developed much more quickly and be rapidly disseminated right across the NHS. The new National Patient Safety Alerting System (NPSAS) will ensure warnings of emerging risks can be rapidly issued following their identification […]
Patient Safety Event Data Quarterly Publication Revised publication This is a planned revision which supersedes the Q4 2024/25 publication originally published on 15th May 2025 Overall, the number of patient safety events increased by 0.6% from the original publication. LFPSE is a live system and records can be added and deleted at any time. This […]
Through its review of recorded patient safety events the National Patient Safety Team identified an issue related to retention of bone cement following hip surgery. An incident described an elderly patient returning to theatre to remove unintentionally retained bone cement, following a hip replacement procedure for a fractured neck of femur. Bone cement is used […]
Through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified issues where ventilators had been left in standby mode. The team reviewed a Serious Incident report describing a […]
Patient Safety Event Data Quarterly Publication 1. National Patient Safety Data Context 1.1. Transition of recording systems NHS England previously published official statistics using National Reporting Learning Service (NRLS) patient safety incident data: the National Patient Safety Incident Reports (NaPSIR), and Organisation Patient Safety Incident Reports (OPSIR). In addition, we published monthly summary data which […]
Patient Safety Event Data Quarterly Publication Revised publication This is a planned revision which supersedes the Q3 2024/25 publication originally published on 10th April 2025 Overall, the number of patient safety events decreased by 0.3% from the original publication. LFPSE is a live system and records can be added and deleted at any time. This […]
This alert temporarily advising against the use in the home of birthing pools with built-in heaters and recirculation pumps, potentially filled up to two weeks in advance of the birth.