This page is part of the wider ‘Aspects of previous patient safety alerts that should inform broader local safety initiatives’ set of webpages.
Past alerts set out requirements for organisations to ensure healthcare staff had access to the information they needed; for example, technical information on a specific medication or resources to support specific clinical conditions.
These alerts applied to situations where staff may still have relied on paper-based materials provided at the point medications are prescribed or administered, or when patient care is assessed. While the principle of ensuring healthcare staff have the information they need at the time they need it remains sound, these resources have often now been updated or encompassed by broad information access via digital solutions.
Past alerts highlighted the importance of having guidance following specific invasive or surgical procedures. The principle that staff and patients should have information to support the early recognition and escalation of serious complications remains sound, but should be applied widely, rather than to the small number of procedures specified in past alerts.
Previous alerts linked to resources current at that time to support the safer care of the deteriorating patient, and prompt recognition and treatment of sepsis. These have been superseded by resources and guidance from the Royal College of Physicians, NICE and other sources.
The related patient safety issues remain clinically significant and are one of the main workstreams of the National Patient Safety Improvement Programme, delivered by the 15 regionally-based patient safety collaboratives (PSC). Where appropriate, organisations should engage with the PSC work and the adoption and spread of improvement approaches.
One past alert addressed a specific aspect of transfusion safety, but the details of good practice at the time have since been superseded. The Serious Hazards of Transfusion scheme (SHOT) deals with issues relating to blood transfusion safety. Organisations should have a process in place to report to SHOT, receive SHOT’s annual report and action the recommendations, as required.
Go back to the main ‘Aspects of previous patient safety alerts that should inform broader local safety initiatives’ webpage.