The alert recommends changes to strengthen clinical governance arrangements, and the identification of medication safety officers (MSOs) and multi-professional groups to review medication error incidents and improve medication safety locally. Improving medication error incident reporting and learning Improving medication error incident reporting and learning – supporting information Patient safety alerts are shared rapidly with healthcare […]

Prevent the spread of carbapenemase-producing Enterobacteriaceae. Rising trends and outbreaks in carbapenemase-producing Enterobacteriaceae Enterobacteriaceae are a large family of bacteria that usually live harmlessly in the gut of all humans and animals, but, in the wrong place, can cause serious infections. Worldwide, a small but increasing number of strains of Enterobacteriaceae have become resistant to […]

An NHS England stage-two ‘resource’ patient safety alert has been issued today (6 March 2014) to signpost providers of NHS care to resources developed to prevent the spread of carbapenemase-producing Enterobacteriaceae. Enterobacteriaceae are a large family of bacteria that usually live harmlessly in the gut of all humans and animals, but, in the wrong place, […]

ECGs are routinely performed to diagnose cardiac problems and there are no risks associated with the test itself, however, there is a risk of associating ECG records with wrong patients leading to misdiagnosis and incorrect treatment. Risk of associating ECG records with wrong patients Patient safety alerts are shared rapidly with healthcare providers via the […]

An NHS England patient safety alert has been issued today (4 March 2014) to all NHS services in England that use ECG machines to diagnose cardiac problems. The alert highlights the risk of printing the wrong patient’s ECG records in error, which could lead to misdiagnosis and incorrect treatment. The alert has been issued following […]

A new report published today by the Surgical Never Events Taskforce has made a series of recommendations for new standards and systems to further improve the safety of surgery in English hospitals. In response, NHS England has committed to identifying practical ways to take forward the report’s recommendations to eradicate never events from surgical procedures. […]

An NHS England patient safety alert has been issued today (20 February 2014) to all hospitals in England who administer spinal (intrathecal) chemotherapy, to minimise the risk of wrong route administration. The alert instructs hospitals to only use syringes and needles, and other devices, with non-Luer connectors when delivering this type of chemotherapy, as they […]

This alert provides new guidance on spinal (intrathecal) devices for chemotherapy that replaces guidance in previous alerts NPSA/2009/PSA004A and NPSA/2011/PSA001. All other guidance in previous alerts remains unchanged. Non-Luer spinal (intrathecal) devices for chemotherapy Non-Luer spinal (intrathecal) devices for chemotherapy (supporting information) Analysis of stakeholder engagement responses Patient safety alerts are shared rapidly with healthcare […]

NHS England and the Society for Cardiothoracic Surgery today commented on the current safety of children’s heart surgery at Bristol Children’s Hospital. It follows last week’s meeting between Sir Bruce Keogh and families of children who died at the hospital, where it was agreed that there should be an independent review, chaired by Sir Ian […]

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 […]