Introducing National Patient Safety Alerts

Changes are being implemented to the way national organisations develop and issue safety alerts to healthcare providers.

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There are a range of national bodies and teams that issue safety communications to healthcare providers about risks of serious harm to patients. In the past this has been done through a variety of means such as alerts, messages and notices.

The National Patient Safety Alerting Committee (NaPSAC) has been established to improve the effectiveness of these safety critical communications and to support providers to better implement the required actions. The key way NaPSAC is doing this is through the introduction of National Patient Safety Alerts.

Changes to national alerts

NaPSAC has developed and is providing governance for the new National Patient Safety Alerts. All national bodies and teams issuing alerts are required to go through a process of accreditation to issue National Patient Safety Alerts that ensures their systems and processes for producing and developing alerts meet NaPSAC’s common standards.

This will ensure:

  • alerts are only issued for safety-critical issues (risk of death or disability)
  • alerts have a concise and clear explanation of the risk
  • the required actions are assessed for feasibility, risk of unintended consequences, equalities impact, effectiveness, and cost-effectiveness
  • the actions are SMART (specific, measurable, achievable, realistic and timely)

The introduction of these new alerts is expected to result in a lower number of national alerts being issued.

National Patient Safety Alerts have a distinct design and unique logo to make them stand out from other safety communications.

What does this mean for providers

As outlined in the alert ‘The introduction of National Patient Safety Alerts’, issued in September 2019, providers are required to fundamentally review their systems for implementing the actions required by National Patient Safety Alerts. This includes revising policies, processes and governance systems to meet the management and oversight requirements for the implementation of these alerts.

National Patient Safety Alerts typically require action to be centrally coordinated on behalf of the whole organisation, rather than by multiple individual teams, divisions or directorates, as had often been the case for previous alerts.

All National Patient Safety Alerts need executive level oversight (or the equivalent in organisations without executive boards) of governance systems that provide evidence that the required actions have been fully completed before any National Patient Safety Alert is recorded as ‘action completed’ on the Central Alerting System (CAS).

Complex and straightforward alerts

Each National Patient Safety Alert is designated as either ‘complex’ or ‘straightforward’, and providers are required to take a different response to each:

  • ‘Complex’ alerts require actions that cannot be delivered by any single division or professional group within an organisation and will require the organisation’s executive leader to nominate a senior clinical leader relevant to the alert to coordinate delivery
  • ‘Straightforward’ alerts may be actioned on behalf of the whole organisation by agreed senior leaders (for example, an agreement that the chief pharmacist will ensure all stocks throughout the organisation are checked for a National Patient Safety Alert requiring removal of a specific drug batch), or may be directed at a specific senior leader relevant to the alert (for example, the head of audiology was identified in a recently issued alert relating to hearing aids).

Changes for CAS officers

A CAS officer at a provider is typically the person who will receive a patient safety alert when issued and has responsibility for updating the CAS system around their organisation’s progress in implementing an alert’s required actions.

The introduction of National Patient Safety Alerts represents a significant change for CAS officers. Rather than disseminating alerts to multiple teams and divisions as they have previously, CAS officers are required to ensure National Patient Safety Alerts rapidly reach the designated executive and relevant senior leader who will be coordinating delivery of an alert’s required actions.

They should only be recording National Patient Safety Alerts as ‘action completed’ on CAS once all actions have been completed and they have the authorisation of the designated member of the executive team.

CQC inspection will focus on implementation of National Patient Safety Alerts, with the potential for regulatory actions for non-compliance.

Background on the new national patient safety alerting system

NaPSAC was established after various insights showed that existing alerting systems were not as effective as they needed to be in preventing the risks they were communicating.

Feedback from providers was that safety-critical communications did not always stand out from other communications, and the required actions were not always clear or effective. It was also found that it was not always made clear when an alert had significant clinical implications, such as a need to recall and review patients, risking those alerts being treated in the same way as more straightforward recalls of drug batches or medical equipment.

CQC’s ‘Opening the door to change’ 2018 report into NHS safety culture, showed that organisations did not always have strong systems for implementing alerts. Key problems included disseminating alerts for local awareness rather than taking the actions the alerts set out, delegating responsibility for recording action had been completed to junior levels of their organisation, and localised implementation that relied on many local team or unit leaders taking duplicative actions, with the most effective systemic actions left incomplete.

Fundamental change was needed, and the National Patient Safety Alerting Committee has worked to deliver that change.

National Patient Safety Alert accreditation process

Bodies and teams accredited to issue National Patient Safety Alerts need to demonstrate how they work with experts, patients and public, and front line staff to achieve these standards. More detail can be found in the National Patient Safety Alert accreditation criteria (see ‘Summary criteria for the management and creation of National Patient Safety Alerts’ below).

Organisations that have achieved National Patient Safety Alert accreditation:

  • NHS England National Patient Safety Team
  • Medicines and Healthcare products Regulatory Agency
  • UK Health Security Agency
  • Office for Health Improvements and Disparity (drugs and alcohol)
  • NHS England Screening Quality Assurance Services
  • NHS England Commercial Medicines Unit and Department of Health and Social Care Medicines Supply Team (joint accreditation)
  • NHS England Estates and Facilities team

All other national alert issuing organisation are currently working towards National Patient Safety Alert accreditation. During this time there will be a period of dual running with some organisations issuing National Patient Safety Alerts while others continue to issue using existing types of alerts, messages and other communications via the Central Alerting System – all must be actioned by providers accordingly.

News and updates

National Patient Safety Alerts issued to date

Share your views

Please use the link below to share your views on the new National Patient Safety Alerts:

Send us your feedback on National Patient Safety Alerts

Summary criteria for the management and creation of National Patient Safety Alerts

NaPSAC terms of reference

Minutes from NaPSAC meetings

As of November 2020, the NaPSAC committee has ceased, however the functions of the committee have been incorporated within the new National Patient Safety Committee.