Patient safety alerts are issued to providers of NHS care to support them to take specific actions to keep patients safe. Although some content of past alerts is outdated, some of the actions from previously issued alerts continue to be relevant and remain valid beyond the timescales of the original alert.
Over 140 alerts issued up to November 2019 (including ‘notices’ or ‘rapid response reports’) were recently clinically reviewed to identify which actions within those alerts remain valid and should be considered as ‘enduring standards’.
The review covered alerts issued by the NHS England and NHS Improvement National Patient Safety Team and its predecessor organisation, the National Patient Safety Agency (NPSA). The review also summarised other content from the alerts identified as general principles that can be applied more widely to inform wider ongoing safety improvement.
The key elements from the review are highlighted on the webpages below. The pages do not set out any new actions for organisations to implement, but act as an aid to support providers to confirm that ‘enduring standards’ from previously completed alerts have been embedded locally, and that the general principles are considered within ongoing patient safety improvement.
The content on these pages replaces any need to directly refer to the full versions of the archived alerts.
- Enduring standards that remain valid – actions from previous alerts identified as an ongoing enduring standard. These enduring standards remain valid and are unlikely to change in the immediate future. They should already be embedded systematically across NHS provider organisations.
- General principles that should inform local safety initiatives – aspects of patient safety that were described in previously issued alerts, but apply much more widely across an organisation. These are often the underpinning principles of good safety systems and good clinical governance. They will likely require a continuous improvement focus, rather than being specific to a speciality or clinical issue. These principles are a helpful basis for ongoing patient safety improvement.
Why we conducted the review
Alerts are different to clinical guidelines. They identify actions that need to be completed by a set date and done once. They are therefore not routinely updated or reissued, although if more effective safety actions are identified, new alerts requiring these actions may be issued.
Many past alerts, especially those that were categorised as ‘Warning’ alerts, had no specific actions. They were issued either to ‘raise awareness’ or to ask for a local action plan to be developed.
‘Resource’ alerts typically asked organisations to adopt guidance published by other organisations. Some of this will now be outdated or has been replaced. The earliest alerts issued by the NPSA are now almost two decades old: safety knowledge and clinical care have changed significantly in that time, hence the reason for undertaking this review to set out the elements that remain valid.
We will continually review the enduring standards and update the information on the webpages as required.