Through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified issues around the compatibility between defibrillators and associated defibrillator pads.
In emergency situations, cardiac defibrillation devices allow timely lifesaving treatment by delivering electric shocks to restore a stable heart rhythm. External defibrillation requires defibrillator pads to be applied to the chest; it is essential these pads are compatible with the defibrillator device.
A serious incident report highlighted an issue regarding incompatibility between defibrillator pads and associated devices. A review of the NRLS identified six related incidents where incompatibility was either identified during routine checks or at the time of use, which resulted in a delay to defibrillation.
We shared these findings with our network of medical device safety officers who represent healthcare providers across the NHS, and the Resuscitation Council UK agreed to communicate the issue of incompatibility to the Resuscitation Officer community via their national membership bulletin. These actions aim to support those managing these devices locally to take steps to ensure defibrillators remain safe and ready for use when needed.
About our patient safety review and response work
The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare.
A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.
You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.
You can also find more case studies providing examples of this work on our case study page.