Another vital step towards keeping patients free from harm

Since the publication of this blog Dr Mike Durkin has left NHS England.

Today sees the launch of the new National Patient Safety Alerting System (NPSAS), a vital tool that NHS England will use to ensure warnings of potential risks to the safety of patients can be swiftly developed and disseminated to every corner of the NHS. Dr Mike Durkin, Director of Patient Safety, explains the importance of the new system and the difference it will make:

Almost all treatments and procedures carried out by staff of the NHS carry some inherent risk to the safety of patients.

However, where there are clearly identified steps that can be taken to prevent a risk, or if a new type of risk has been identified, it is vital we are able to share that information as soon as possible across the whole healthcare system to keep our patients safe.

This is why today we have launched the new National Patient Safety Alerting System, an improved, more flexible and more effective method for highlighting risks in patient care and to provide resources and clear guidance on eliminating risks.

The new alerting system will also make NHS providers more accountable for implementing and complying with the required actions of each alert we issue.

The system takes a three-stage alerting approach based on those used in other high-risk industries, such as aviation. Now, when a potential risk to safety is identified by NHS England, it is likely the following process will be followed:

  • A Stage One “warning” alert will be issued to ensure healthcare staff are made aware of the potential issue at the earliest opportunity. This allows hospitals, clinics and other healthcare organisations to assess similar risks in their own organisations, so that immediate action can be taken. Providers may also be asked to share examples of any existing or newly implemented procedures and resources that have proved to be successful at a local level in preventing the risk.
  • If the Stage One alert requires further action, a Stage Two “resource” alert will follow, with more in-depth information and advice. Stage Two alerts will include examples of good practice to mitigate the risk that have been shared by providers following a Stage One alert;  as well as access to resources to help introduce new measures to reduce risks; and access to relevant training programmes.
  • If necessary, a Stage Three “directive” alert will follow, requiring organisations to confirm they have undertaken specific actions and introduced specific processes to mitigate the risk.  Providers will be issued with a checklist of required actions, tailored to the individual issue or risk, and will need to confirm these actions have been taken within a set timeframe.

The new system will ensure no identified risk or potential risk to patient safety gets held up in a long process of consultation and discussion before being highlighted to those at the frontline in healthcare who will need to take action.

As with previous patient safety alerting systems, NPSAS alerts will be issued via the Central Alerting System (CAS), allowing us to quickly cascade alerts to every single healthcare setting either directly, or in the case of primary care, via the NHS England Area Teams.

The new system builds on the alerting systems used previously by the former National Patient Safety Agency (NPSA), whose responsibilities have now been transferred to NHS England.

Those systems were effective; however, the development, consultation and agreement process was lengthy, meaning it was often difficult to issue timely alerts.

A benefit of the speed of the new system could clearly be seen last December, when we were able to issue our first alert using the system within just 10 days of a risk being identified involving the placement of naso-gastric tubes.

Another key feature of the system is that it offers a two-way function, in that providers will be encouraged to share their own successful practice in addressing a particular risk with the NHS England Patient Safety Domain. This vital learning will then help inform the development of tools and resources that will be cascaded to similar providers across the country through a further alert to ensure proven solutions are implemented, and that staff are equipped with the knowledge and skills to prevent and avoid the risk.

Providers of NHS care will also be made more accountable for fulfilling the requirements of an alert through the monthly publishing of data on the NHS England website that will name any trust who fails to declare they have complied with any of the three stages of alert within the set timeframes.

This information will be publicly available and we expect it to be used by the CQC as part of their systems for identifying trusts in need of inspection, and by other regulators and commissioners in holding their local services to account.

Where possible we will always ensure each patient safety alert is developed with input from a range of experts and that they are owned and developed by the most relevant of the six NHS England patient safety expert groups (PSEGs). These groups are made up of a core multi-professional membership including representation from relevant colleges and associations, patient and carer groups, NHS England and CCGs to focus on a particular area of care.

There may be occasions when we need to act with speed to alert providers about an urgent issue, therefore, we have also built in the flexibility that as Director of Patient Safety, I can take the responsibility for sponsoring an alert to ensure we can highlight the risk and any initial preventative actions as quickly as possible.

I am certain the new National Patient Safety Alerting System will be another effective tool in helping keep patients safe across the NHS. Patient safety is now more than ever at the forefront of the minds of those providing NHS care, and thanks to the efforts of frontline staff we are continuing to take great strides in making healthcare settings safer and preventing harm to patients, and this new system will only further support those providing care.

Last year, in his landmark review into patient safety in England, Professor Don Berwick said the NHS has the potential to become the safest healthcare system in the world. He specifically recommended improvements to how we alert the system to known risks, a priority of the patient representatives on his advisory group.  We are determined to make the NHS the safest healthcare system in the world, and this new alerting system is an important step towards that goal.

Dr Mike Durkin was previously Director of Patient Safety, since the publication of these blogs he has left NHS England.

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