These alerts require action to be taken by healthcare providers to reduce the risk of death or disability.
We are continuing to routinely process and review patient safety incident reports and, where appropriate, use this information to identify actions that organisations can take to reduce risks. These actions will be issued in the form of National Patient Safety Alerts. However, alerts will be prioritised to take account of current COVID-19 circumstances and the actions required will reflect what is feasible at this time.
Providers are encouraged to continue to work to become compliant with present and future alerts, but they should be pragmatic about what is possible and at all times prioritise the delivery of frontline healthcare. Providers will not be penalised for prioritising care over alert compliance.
Protecting patients from harm
New or under-recognised patient safety issues that require national action are identified through clinical review of incidents reported to our national reporting system and other sources. When we identify these issues, we work with frontline staff, patients, professional bodies and partner organisations to decide if we can influence or support others to act or, if we need to, we will issue a National Patient Safety Alert that sets out actions healthcare organisations must take to reduce the risk.
This process does not include the more common patient safety challenges, such as reducing diagnostic error, preventing self-harm, avoiding falls or managing long-term anticoagulation, as they are already well recognised. These ‘giants’ of patient safety have complex causes and no simple solutions, and are the focus of long-term programmes; including our National patient safety improvement programmes, as outlined in the NHS Patient Safety Strategy.
National Patient Safety Alerts
In November 2019 we began issuing alerts as ‘National Patient Safety Alerts’.
Our patient safety team was the first national body accredited to issue National Patient Safety Alerts by the National Patient Safety Alerting Committee (NaPSAC). All National Patient Safety Alerts are required to meet NaPSAC’s thresholds and standards, which include working with patients, frontline staff and experts to ensure alerts provide clear, effective actions to reduce the risk of death or disability.
To support us to do this, our alerts are developed with input, advice and guidance from the ‘National Patient Safety Response Advisory Panel‘, which brings together frontline healthcare staff, patient representatives, safety experts, royal colleges and other professional and national bodies.
How we decide if a patient safety issue, meets the criteria for a Patient Safety Alert
Our decision flow chart for patient safety alerts – This flowchart shows how we decide if a patient safety issue meets the criteria for a national patient safety team patient safety alert.
Healthcare providers and National Patient Safety Alerts
NaPSAC requires healthcare providers to introduce new systems for planning and coordinating the actions required by any National Patient Safety Alert across their organisation, and must include executive oversight. This is essential for effective delivery of systematic actions to protect staff from error and protect patients from risk of death or disability.
Failure to take the actions required under any National Patient Safety Alert may lead to CQC taking regulatory action. Declared compliance with alerts is a key safety indicator, and compliance with National Patient Safety Alerts is a focus of CQC inspection.
List of our National Patient Safety Alerts (alerts issued since November 2019)
National Patient Safety Alerts issued by our national patient safety team since 1 November 2019:
- Transition to NRFit™ connectors for intrathecal and epidural procedures, and delivery of regional blocks – 31 January 2024
- Identified safety risks with the Euroking maternity information system – 7 December 2023
- Use of oxygen cylinders where patients do not have access to medical gas pipeline system – 10 January 2023
- Inadvertent oral administration of potassium permanganate – 5 April 2022
- Infection risk when using FFP3 respirators with valves or Powered Air Purifying Respirators (PAPRs) during surgical and invasive procedures – 25 August 2021
- Elimination of bottles of liquefied phenol 80% – 25 August 2021
- Inappropriate anticoagulation of patients with a mechanical heart valve – 14 July 2021
- Eliminating the risk of inadvertent connection to medical air via a flowmeter – 16 June 2021
- Urgent assessment/treatment following ingestion of ‘super strong’ magnets – 19 May 2021
- Deterioration due to rapid offload of pleural effusion fluid from chest drains – 1 December 2020
- Foreign body aspiration during intubation, advanced airway management or ventilation – 1 September 2020
- Steroid Emergency Card to support early recognition and treatment of adrenal crisis in adults – 13 August 2020
- Risk of death from unintended administration of sodium nitrite – 6 August 2020
- Blood control safety cannula and needle thoracostomy for tension pneumothorax – 2 April 2020
- Interruption of high flow nasal oxygen during transfer – 1 April 2020
- Ligature and ligature point risk assessment tools and policies – 3 March 2020
- Risk of harm to babies and children from coin/button batteries in hearing aids and other hearing devices – 13 December 2019
- Risk of death and severe harm from ingesting superabsorbent polymer gel granules – 29 November 2019
- Depleted batteries in intraosseous injectors– 5 November 2019
Enduring standards and general principles from previously issued patient safety alerts
We have published a set of ‘enduring standards and general principles’ to highlight actions within previous patient safety alerts that remain valid today, and are unlikely to change in the immediate future, as well as those that underpin wider patient safety work. The standards have been published following a clinical review of Patient Safety Alerts issued up to November 2019 by the NHS England and NHS Improvement National Patient Safety Team and its predecessor organisations.
The guidance acts as an aid to support providers to confirm the identified ‘enduring standards’ from previously completed alerts are embedded locally, and that the general principles are considered within wider ongoing patient safety improvement.
Previous alerts (issued October 2019 to December 2013)
Patient safety alerts issued by our national patient safety team prior to the introduction of National Patient Safety Alerts in November 2019 can be found via the search section of the Central Alerting System (CAS) website.
- Select ‘NHS Improvement’ as alert originator to find alerts issued October 2019 – April 2016
- Select ‘NHS England’ as alert originator to find alerts issued March 2016 – December 2013
National Patient Safety Agency (NPSA) Alerts (alerts issued prior to April 2012)
Alerts issued prior to 1 April 2012 are available via the archived National Patient Safety Agency (NPSA) website.
Please note: The alerts and guidance that remain available on the archived NPSA website should be used with great caution.
NPSA alerts were only updated to reflect changes in current safety knowledge or clinical care that applied at the point their ‘action compete’ date was reached. Some of these ‘action complete’ dates for alerts, safety notices and rapid response reports occurred almost 20 years ago.
Alerts have a distinctly different function to clinical guidelines and therefore are not routinely updated or reissued. When new, more effective interventions or resources to address a patient safety issue are identified, the potential to issue a new National Patient Safety Alert will be considered.
Enduring barriers established by NPSA alerts to prevent Never Events are summarised alongside the Never Events policy and framework.
Our alerts are developed with input, advice and guidance from the ‘National Patient Safety Response Advisory Panel’, which brings together frontline healthcare staff, patient representatives, safety experts, royal colleges and other professional and national bodies.
Membership is made up of representatives from:
- Frontline healthcare providers
- NHS England
- Patient representatives
- National Association of Medical Device Educators and Trainers
- National Association for Safety and Health in Care Services
- Royal College of Anaesthetists
- Royal College of Emergency Medicine
- Royal College of General Practitioners
- Royal College of Midwives
- Royal College of Obstetricians and Gynaecologists
- Royal College of Ophthalmologists
- Royal College of Paediatrics and Child Health
- Royal College of Pathologists
- Royal College of Psychiatrists
- Royal College of Radiologists
- Royal College of Surgeons
- Royal Pharmaceutical Society
- Observers from each of the devolved nations, and the Healthcare Safety Investigation Branch