Patient safety alert – The risk of using different airway humidification devices simultaneously

January 27, 2016

Source:  NHS England

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Date of publication:  December 2015

Publication type:  Safety alert

In a nutshell: A joint patient safety alert has been issued by NHS England and the Medicines & Healthcare Products Regulatory Agency (MHRA) to raise awareness of the risk of having two different types of airway humidification devices simultaneously connected to a patient’s ventilation equipment.

There are two humidifiers in common use: heated [water] humidifiers (HHs), usually located between the ventilator and the breathing system; and heat and moisture exchangers (HMEs), placed at the patient’s end of the breathing system. The inadvertent use of both types of humidifier simultaneously can cause the HME to become saturated with water and could lead to the airway becoming obstructed.

NHS providers are asked to take local action to prevent the risk.

Length of publication:  1 webpage

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Patient safety alert – The importance of checking vital signs during and after restrictive interventions/manual restraint

December 23, 2015

Source:  NHS England

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Date of publication:  December 2015

Publication type:  Safety alert

In a nutshell:  A patient safety alert has been issued by NHS England to raise awareness of the importance of taking, recording and responding to vital signs where restraint has been used to manage a person’s behaviour if they are at risk to themselves or others.

Length of publication:  1 webpage


Patient safety alert – Risk of death and serious harm by falling from hoists

November 25, 2015

Source: NHS England

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Date of publication: October 2015

Publication type: Safety alert

In a nutshell:  A joint patient safety alert has been issued by NHS England and the Medicines & Healthcare products Regulatory Agency (MHRA) to highlight the risk of falls from hoists.  A National Reporting and Learning System (NRLS) search identified that there have been 15 incidents in a recent four year period where a person has come to harm through falls from hoists, including one death and three severe injuries.  Providers of NHS funded care have been asked to raise awareness of the risk amongst staff and to ensure they have an action plan underway to reduce the risk of these incidents occurring.

Length of Publication: 1 webpage


Patient safety alert – Support to minimise the risk of distress and death from inappropriate doses of naloxone

November 25, 2015

Source:  NHS England

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Date of publication: October 2015

Publication type: Safety alert

In a nutshell: A patient safety alert has been issued by NHS England to support providers of NHS funded care to minimise the risk of distress and death caused by inappropriate doses of naloxone.  The new ‘Stage 2: Resource’ alert highlights a number of resources now available to help providers ensure their local protocols and training related to naloxone reflect best practice.

Length of Publication: 1 webpage


Patient safety alert on standardising the early identification of Acute Kidney Injury

June 25, 2014

Source:  NHS England

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Date of publication:  June 2014

Publication type:  News item

In a nutshell:  A patient safety alert on standardising the early identification of Acute Kidney Injury (AKI) has been issued by NHS England. All NHS acute trusts and foundation trusts providing pathology services have received the alert. A national algorithm, standardising the definition of AKI has been agreed, which has been endorsed by NHS England. It is recommended that the algorithm is implemented across the NHS.

Length of Publication:  1 web page


Patient safety alert on risk of using vacuum and suction drains when not clinically indicated

June 25, 2014

Source:  NHS England

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Date of publication:  June 2014

Publication type:  News item

In a nutshell:  NHS England has issued a patient safety alert on the risk of using vacuum and suction drains when not clinically indicated. The alert has been issued following the report of a serious incident to the National Reporting and Learning System (NRLS). Two further similar incidents had been reported to the NRLS previously. There is a link available to the full patient safety alert.

Length of Publication:  1 web page


Patient safety alert to improve reporting and learning of medication and medical devices incidents

April 30, 2014

Source:  NHS England

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Date of publication:  March 2014

Publication type:  News item

In a nutshell:  Two patient safety alerts have been issued by NHS England and the Medicines and Healthcare products Regulatory Agency (MHRA) to help healthcare providers increase incident reporting for medication errors and medical devices. The alerts will improve data report quality and will see the establishment of national networks to maximise learning and provide guidance on minimising harm in relation to these types of incidents. The alerts call on large healthcare provider organisations across a range of healthcare sectors and healthcare commissioners to identify named leaders in both medication and medical device safety roles. The leaders will be supported by two new national networks for medication and medical device safety.

Length of Publication:  1 web page