National Patient Safety Alerts (PSAs)

National Patient Safety alerts are issued by the Central Alerting System (CAS) to communicate actions required by healthcare providers to be undertaken to reduce the risk of death or disability.

These alerts set out actions that healthcare organisations must take to reduce an identified risk.  Failure to take the actions required under any National Patient Safety Alert may lead to the Care Quality Commission (CQC) taking regulatory action.

Central Alerting System (CAS)

The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance.  This system is used to disseminate information to the NHS and others, including independent providers of health and social care.

Receiving an alert

Most organisations will have a generic email address for receiving CAS alerts.  All organisations should have processes and a governance structure in place to ensure that alerts are cascaded appropriately.

Closing an alert

Once an organisation has completed all the actions required of an alert, the organisation must respond via CAS.  NHS Trusts and Foundation Trusts which have any national patient safety alerts which have reached their deadline but remain open within the central alerting system will be published on the CAS website.

Organisational response

An organisation should have a governance structure in place to provide assurance that all medicines related alerts and notifications are acknowledged and led by a nominated person; in some organisations all alerts and notifications are noted at a Patient Safety Committee (or equivalent) where the lead is nominated.

Nominating a lead

An operational lead is required to ensure delivery of any required actions from an alert, but executive oversight is required to ensure the board has assurance and to aid embedding actions across the organisation.

Where the alert is medication relation, consideration should be given to whether the Medication Safety Officer (MSO) is the most appropriate operational lead.  As a minimum, the MSO should be asked to be part of the multidisciplinary team co-ordinating the organisational response under another nominated lead.

Deadline for actions

It is important that the review and implementation process starts immediately.  Actions should be given a realistic timeframe to ensure delivery before the deadline

Where immediate actions are required the alert or notification will include a shorter deadline.

Acting on safety alerts and notifications

Practical steps

• confirm whether the alert is relevant for the organisation
• scope the extent of the risk in the organisation
• initiate stakeholder engagement
• use opportunities for collaborative working and relevant communication channels
• consider the benefit of establishing a Short Life Working Group (SLWG)
• develop a local action plan, including the expected evidence that will support compliance
• allocate a named lead individual for each action/output
• provide regular operational progress updates
• escalate concerns or barriers to completion with the alert timeframe

Scoping

There are a number of methods to gain intelligence on the extent of the issue within the organisation.  Examples include

• dispensing reports to identify product usage
• discussion with lead clinical experts, and
• liaising with professional leads

Stakeholder engagement

Engagement with all key stakeholders ensures an organisational wide response, incorporating all systems and users of the medicine.

Engagement will

• ensure effective communication of both the risk, local issues and any change required
• ensure that the impact of any proposed change is considered
• encourage the development of local champions which is essential for any sustained change, and
• support the timely delivery of the action plan

Identification of stakeholders

Stakeholders should be multidisciplinary and include:

• strategic leaders (decision makers)
• clinical experts (related to the issue)
• pharmacy representation, including the Medication Safety Officer (MSO)
• frontline users from across the organisation
• system representation (where issues span across care interfaces)
• patients (where appropriate)

Escalation

Where there are concerns or identified barriers to delivering the action plan within the required time frame these should be escalated in a timely fashion through the agreed organisational mechanism. In some organisations this will be the Patient Safety Group, or it could be directly to the named executive lead.  Escalation can prompt support with engagement, identification of solutions and may release capacity.

Compliance

Consideration should be given to how the organisation will demonstrate that it meets the requirements of the alert and methods to ensure these are sustained.

Sustained compliance

Consideration should be given to how the organisation will sustain compliance with the safety recommendations of an alert. The alert action plan should promote embedding change and the continual review of practice and systems

Methods to give confidence of sustained compliance include assurance reports, audit and spot checks.

Historical alerts

There are a number of alerts previously issued, where the deadline has passed and the organisation has declared that all actions have been completed. NHSE 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 alerts with aspects that should inform broader local safety initiatives.