Patient safety alert – Risk of severe harm or death when desmopressin is omitted or delayed in patients with cranial diabetes insipidus

Source:  NHS England

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Date of publication: February 2016

Publication type:  Safety alert

In a nutshell:  A patient safety alert has been issued by NHS England to raise awareness of the risk of severe dehydration and death caused by an omission or delay of desmopressin in patients with cranial diabetes insipidus.

Following reports of patient safety incidents caused by an omission or delay in the provision of desmopressin, providers of NHS care are asked to consider if immediate action needs to be taken locally to raise awareness and reduce the risk of these incidents from occurring. The main themes identified as causes include a lack of awareness of the critical nature of desmopressin amongst medical, pharmacy and nursing staff; and poor availability of the medication within inpatient clinical areas.

Length of publication:   1 webpage

East Cheshire implements iPad safety system

Source:  Health Service Journal 1, September 2014

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Date of publication:  September 2014

Publication type:  News item

In a nutshell:  An iPad based system funded by the Nursing Technology Fund is being used by nurses at East Cheshire Trust to monitor patient safety. Macclesfield Hospital has begun recording clinical data electronically on handheld devices at the patients’ bedside, replacing the standard practice of recording observations on a paper chart at the end of the bed. Nurses input vital signs and other clinical observations into the devices, and the “VitalPAC” system automatically calculates a risk score which will alert staff immediately to any deterioration and provide advice on an appropriate response. The system is to be rolled out to all inpatient wards at Macclesfield Hospital.

Length of Publication:  1 web page

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library

Six-monthly patient safety incident data shows incident reporting in the NHS continues to improve

Source:  NHS England

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Date of publication:  May 2014

Publication type:  News item

In a nutshell: Six-monthly data on patient safety incidents reported to the National Reporting and Learning System (NRLS) has been published from between 1 April and 30 September 2013. According to the data, the NHS is continuing to get better at recognising and reporting patient safety incidents. The new data shows an increase of 8.9% in the number of incidents reported compared to the same period in the previous year, as the NHS continues to be more open and transparent around patient safety incident reporting. It will enable NHS England to identify and take action to prevent emerging patterns of incidents on a national level via patient safety alerts. Locally incident reporting enables clinicians to learn from their own and others’ services about why patient safety incidents happen and they can then act to prevent their own patients being placed at similar risks.

Length of Publication:  1 web page

Patient safety alert on addressing rising trends and outbreaks in carbapenemase-producing Enterobacteriaceae

Source:  NHS England

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Date of publication:  March 2014

Publication type:  News item

In a nutshell:  An NHS England stage-two ‘resource’ patient safety alert has been issued to signpost providers of NHS care to resources established to avoid the spread of carbapenemase-producing Enterobacteriaceae. A small but increasing number of strains of Enterobacteriaceae have become resistant to carbapenem antibiotics. This patient safety alert is for NHS acute trusts and private hospitals providing NHS funded care and it signposts providers to a toolkit developed by Public Health England to support the NHS to control existing transmission problems and to prevent the further spread of infection.

Length of Publication:  1 web page

Patient safety alert on non-Luer spinal (intrathecal) devices for chemotherapy

Source:  NHS England

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Date of publication:  February 2014

Publication type:  News item

In a nutshell: An NHS England patient safety alert to all hospitals in England administering spinal (intrathecal) chemotherapy has been issued to minimise the risk of wrong route administration. Connection with intravenous devices is not permitted, so the alert instructs hospitals to only use syringes and needles, and other devices, with non-Luer connectors when delivering this type of chemotherapy. No incidents of this kind have been reported in England since 2001, but they have happened in Europe and worldwide.

Length of Publication:  1 web page

Another vital step towards keeping patients free from harm

Source:  NHS England

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Date of publication:  January 2014

Publication type:  News item

In a nutshell:  The new National Patient Safety Alerting System (NPSAS) has been launched. NPSAS is an important tool that NHS England will use to ensure warnings of potential risks to the safety of patients can be swiftly developed and disseminated to every part of the NHS. The Director of Patient Safety, Dr Mike Durkin, discusses the difference it will make in this news item.

Length of Publication:  1 web page

NHS trusts put patients’ lives at risk by ignoring safety guidelines.

Source:  British Journal of Nursing Vol 19 Iss 17 p1124-1125

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Date of publication:  September 2010

Publication type:  Journal Article

In a nutshell:  This article looks at the recent Action Against Medical Accidents (AvMA) report and discusses the role of patient safety alerts in the NHS, and the widespread failure of trusts to follow up on these and ensure compliance.

Length of publication:  1 page

Some important notes:  Please contact your local NHS Library for the full text of the article.  Follow this link to find your local NHS Library.

Acknowledgement:  CINAHL