Trusts ignoring NPSA alerts

16 February 2010

Three quarters of trusts in England have failed to comply with at least one National Patient Safety Agency (NPSA) alert since 2004 according to a report published by the charity Action against Medical Accidents (AvMA).

The report Adding Insult to Injury – NHS failure to implement patient safety alerts (PDF) is based on a Freedom of Information request made to the Central Alert System (CAS) which is managed by the Department of Health. It examined compliance in regard to 53 alerts and found that over 300 NHS trusts had not undertaken required actions in at least one patient safety alert for which a deadline had already passed.

It also found 2,124 separate incidences of patient safety alerts not having been complied with by NHS trusts and that 80 trusts had not complied with 10 or more separate alerts.

NPSA alerts cover a range of issues including safe use of injectable medicines, notices designed to reduce the risk of patients being injured falling from beds, administration of opioid medicines and avoiding serious errors in the placement of nasogastric tubes.

AvMA Chief Executive, Peter Walsh, called the results shocking and further commented:

"We all know that mistakes can happen, but there can be no excuse for not acting on patient safety alerts. It is also incredibly worrying that there is no system in place to monitor compliance with these alerts and to intervene where necessary."