Are Trusts ‘failing on safety alerts?'

According to a recent study by Action Against Medical Accidents (AvMA), hundreds of health trusts have failed to take action on patient safety alerts, potentially putting patients' lives at risk.

The National Patient Safety Association (NPSA) analyses reports of patient safety incidents and, using these reports, develops advice on patient safety to be used by the NHS. When issues arise, the Central Alerting System in England and Wales is used to release alerts directly to health trusts. Alerts cover a wide range of topics, from vaccines to patient identification. Types of alerts include Rapid Response Reports, Patient Safety Alerts, and Safer Practice Notices. The advice released is designed to minimise the risk to patients in NHS care through mistakes involving drugs, surgery or other procedures. Once an alert has been released, the NHS is required to take some form of action in response.

Is the message getting through?

However, the report by AvMA suggests that almost 75% of hospitals in the UK have failed to act upon 53 alerts released over the five years between 2004 and 2009. These alerts included one concerning injectable medicines. This alert was issued after 25 deaths and 28 cases of serious harm were reported between January 2005 and June 2006. Others tackled hand washing to prevent the spread of serious infections, action to avoid feeding tubes being fitted incorrectly and action to improve safety for patients receiving high doses of morphine.

Peter Walsh, the Chief Executive of AvMA, has stated that "lives are being put at risk". The AvMA has uncovered around 200 trusts that have failed to react to an alert that was released five years ago. In response, the Department of Health stated that, "We expect all NHS trusts to comply with safety alerts and to record and action them. However, not all organisations may be updating the system reliably and in a timely fashion. The Department will shortly be issuing all NHS organisations a formal reminder of their obligations to do this." However, Mr. Walsh has said that, "there is actually no system in place to systematically monitor compliance and follow-up with the trusts".

The ramifications of failing to act on alerts can be well observed in a report made by Channel 4. The report studied the death of Paul Richards from an overdose of a cancer drug in 2007. His wife subsequently learned that the hospital caring from him had failed to act upon an alert about injectable medicines, which could have saved his life. Shortly after Mr. Richards' death, an alert was released to hospitals, specifically about the cancer drugs involved. Mrs. Richards has since learned that 10 NHS trusts have failed to take this advice on board, giving credence to Mr. Walsh's statement about lives being out at risk.

However, the Department of Health is keen to implement safety measures, stating that from April 2010, all NHS Trusts will be required to register with the CQC (Care Quality Commission). From this point, it will be mandatory for NHS organisations to report serious patient safety incidents, improving identification and monitoring of incidents.

This situation and the trusts' reactions to the criticisms being levelled at them for their lack of response to alerts could have serious implications for patients who feel that their care has been compromised as a result. Also watching with interest are the legal organisations representing those patients bringing compensation claims against the NHS for lapses in care or treatment standards. If it is shown that NHS trusts are not responding correctly to these alerts, it could be that we see an increase in the number of people with justifiable reasons to sue the NHS.