A new alerting system launched by NHS England will ensure warnings of potential risks to the safety of patients can be developed much more quickly and be rapidly disseminated right across the NHS.
The new National Patient Safety Alerting System (NPSAS) will ensure warnings of emerging risks can be rapidly issued following their identification by the NHS England Patient Safety Domain. As part of the new process, by April 2014, NHS England will also begin publishing monthly data on Trusts who fail to confirm they have complied with the required actions of an alert within the set timeframe.
Until now, information about risks identified through the National Reporting and Learning System (NRLS) has been distributed through a range of different mechanisms including Patient Safety Alerts and Rapid Response Reports. This system was effective, but the development, consultation and agreement process was lengthy, meaning it was often difficult to issue timely alerts. The new system has three stages and is based on those used in other high-risk industries like aviation. Now, when a potential risk to safety is identified:
• A Stage One ‘warning’ alert is issued to ensure healthcare staff are made aware of the potential issue at the earliest opportunity. This allows hospitals, clinics and other healthcare organisations to assess similar risks in their own organisations, and take immediate action.
• If the Stage One alert requires further action, a Stage Two ‘resource’ alert will follow, with more in-depth information and advice. Stage Two alerts will include examples of good practice to mitigate the risks that have been shared by providers following a Stage One alert; access to resources to help introduce new measures to reduce risks; and access to relevant training programmes.
• If necessary, a Stage Three ‘directive’ alert will be issued, requiring organisations to confirm that they have undertaken specific actions and introduced specific processes to mitigate the risk. Providers will be issued with a checklist of required actions, tailored to the individual issue, and will need to confirm these actions have been taken within a set timeframe.
Alerts will be distributed through the Central Alerting System, which is already used to send out alerts from other bodies, such as Medicines and Healthcare Products Regulatory Agency (MHRA) and the Chief Medical Officer.
Trusts who fail to declare they have complied with any of the three stages of alert within the set timeframes will be named in monthly data, which will start to be published on the NHS England website by April 2014. This information will be publicly available and it is likely to be used by the CQC as part of their systems for identifying Trusts in need of inspection.
