Aspects of previous patient safety alerts that should inform broader local safety initiatives

Following a clinical review of previous patient safety alerts issued up to November 2019 by the NHS England and NHS Improvement National Patient Safety Team, or its predecessor organisation, the National Patient Safety Agency (NPSA), this webpage sets out aspects from those alerts that have been identified as continuing to apply to broader patient safety initiatives across organisations providing NHS funded care.

These aspects are often the underpinning principles of good safety systems and good clinical governance that require a continuous improvement focus, rather than being specific to a speciality or clinical issue. They are a helpful basis for developing local safety initiatives.

This page should be read alongside our main enduring standards and general principles from previously issued patient safety alerts webpage.

You can also view our enduring standards that remain valid from previous Patient Safety Alerts webpage to access standards relating to more specific specialities or clinical issues.

The content on these pages replaces any need to directly refer to the full versions of the archived alerts.

How to use this content

The aspects from previous alerts webpages listed below do not set out any new actions for organisations to implement, but act as a helpful basis for developing local safety initiatives and a basis for ongoing patient safety improvement.

This content is intended to replace any need to directly refer to the original alerts. However, we have provided links for reference.

Material in past alerts should be used with caution, with consideration given to its current relevance, unless specifically highlighted below or as an enduring standard.

As outlined on the ‘Enduring standards that remain valid from previous Patient Safety Alerts’ page, staff should be familiar with guidance from national organisations, some of which has been specifically developed in response to previous alerts, including Royal Pharmaceutical Society, Specialist Pharmacy Service, MHRA and other regulatory bodies.

This content remains best practice as at the date this page was last reviewed (February 2022), and will be updated as required. However, please be aware that these standards may be superseded by any subsequent guidance issued by a national body, including subsequent National Patient Safety Alerts and NICE clinical guidelines.

The content is categorised on individual webpages covering the following areas:

Overall safety systems

  • Training and competency
  • Audits
  • Policies and procedures
  • Access to ‘kits’ to streamline response to emergencies
  • Risk assessment

Linking with national systems

  • Improving incident reporting
  • Nominated safety officers/safety specialists

Purchasing for safety

  • Connectors to reduce the risk of wrong-route enteral, intravenous and spinal/intrathecal administration
  • Selecting medication presentations for safety

Empowering patients

  • Information for patients and patient-held records
  • Self-administration and self-care

Priority setting

  • Prioritising local safety improvement work for medication

Information for healthcare professionals

  • Access to appropriate clinical guidance/information for healthcare professionals
  • Guidance for specific procedures
  • Deterioration and sepsis
  • Blood transfusion safety

Personal responsibilities

  • Staff personal awareness and vigilance
  • Checks before prescribing/dispensing/administering