Safety recommendation
It is recommended that NHS Improvement, through the National Patient Safety Alert Committee, set standards for all issuers of patient safety alerts which make clear that alert issuers should assess for unintended consequences of the actions in the alert, the effectiveness of barriers created by these actions, and provide appropriate advice for providers on implementation, include ongoing monitoring.
Response:
As chair of the National Patient Safety Alert Committee, whose members include all arms-length bodies and teams who issue national safety guidance in the form of alerts, I [Dr Aidan Fowler, National Director of Patient Safety] welcome the recommendation from HSIB.
I can confirm that the standards that the National Patient Safety Alert Committee agreed in 2018 include, amongst other criteria, that: “There is a procedure for the development of actions required in the National Patient Safety Alert that includes: an assessment of the actions for potential unintended consequences is carried out [and] an assessment of the likely effectiveness of the actions in reducing future harm is carried out.”
These standards also include a requirement that “The system [of each alert-issuing body] sets out what types of supporting materials should be provided by the alert issuing team/body for complex National Patient Safety Alerts.” This requirement encompasses materials to support providers with implementation and ongoing monitoring where this is required; we would not expect this support to be required for some National Patient Safety Alerts that are straightforward (for example, some types of drug or device recall) or National Patient Safety Alerts that contain systemic actions that once taken eliminate the need for ongoing monitoring. A key aspect of the work of NaPSAC is the role of CQC in inspecting compliance with National Patient Safety Alerts and where appropriate using its regulatory powers.
The NaPSAC standards became active on 13 May 2019 and the first alert-issuing body is currently preparing its application to become a credentialled issuer of National Patient Safety Alerts. Progress will be publicly reported on NaPSAC webpages.
Response received on 15 July 2019.