Response to AvMA report: Patient safety alerts

  • 28th January 2020
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Today Action against Medical Accidents(AvMA) have released a new report, An organisation losing its memory?, which looks at the implementation and monitoring of patient safety alerts.

Report findings

The report, authored by Dr David Cousins, sets out some concerning findings relating to the progress being made by NHS trusts in implementing recommendations from patient safety alerts and how their compliance is monitored. Patient safety alerts are intended to warn the healthcare system of risks and provide guidance on preventing potential incidents that may lead to harm or death.[1]

The study drew on patient safety compliance data, published by NHS Improvement in 2019, and Freedom of Information (FOI) requests to the trusts listed as non-compliant on patient safety alerts. It also involved FOI requests to NHS Improvement and the Care Quality Commission (CQC) relating to the actions taken to support and check the implementation of this guidance.

It highlights problems implementing patient safety alert guidance in individual trusts and serious delays in introducing safer practices. It also raises concerns about the monitoring system at a national level, commenting that that the ‘role and responsibility of national organisations to oversee the implementation of these alerts was unclear and ineffective in some cases’.[2]

Data-rich, information poor

NHS trusts report incidents to the National Reporting and Learning System (NRLS), a central database of patient safety incident reports. This information is then used to spot emerging patterns and develop guidance and alerts to protect patients from harm.

It’s concerning that the NHS does not appear to have a robust system for monitoring the implementation of patient safety alerts that are produced by this process. It should not be the case that this information is only made publicly available when a charity uses FOI requests to obtain the details, and it is disappointing that NHS Improvement did not provide the information in AvMA’s FOI request, citing an exemption on cost grounds.

In our report, A Blueprint for Action, we highlight data and insight for patient safety as one of the six foundations of safe care. [3] We need the health and social care system to develop models for measuring, reporting and assessing patient safety performance if we are to identify and address shortfalls in performance.

A gap in oversight

The report highlights gaps in monitoring the implementation of patient safety alerts at a national level and calls for a ‘more robust and proactive system of monitoring and regulating compliance with patient safety alerts’.[4] The report suggests this role could potentially be performance by the CQC or NHS Improvement.

At Patient Safety Learning we'd ask whether the National Patient Safety Alerting Committee (NaPSAC) might be best placed to perform this role. This body’s core purpose is to ‘agree progress and oversee systems that will clearly identify which nationally-issued patient safety advice and guidance is safety-critical’.[5] With its central role in the existing reporting system, could its remit be revised to address this current oversight gap?

The need for a culture shift

At Patient Safety Learning we believe patient safety is not just another priority; it’s part of the purpose of health care. Patient safety should not be negotiable. If we are going to get serious about tackling this avoidable harm in healthcare, then this needs to be accompanied with a shift to a Just Learning culture where difficult questions aren’t simply swept under the carpet. It’s important NHS England and NHS Improvement respond on this report’s important findings and make a considered response to the recommendations set out in this.

[1] NHS Improvement, Patient Safety Alerts, Last Updated: 14 March 2018.

[2] AvMA, An organisation losing its memory? Patient safety alerts: implementation, monitoring and regulation in England, January 2020.

[3]Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019.

[4] AvMA, An organisation losing its memory? Patient safety alerts: implementation, monitoring and regulation in England, January 2020.

[5] NHS Improvement, National Patient Safety Alerting Committee, Last Updated: 16 September 2019,


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