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  1. The alert recommends changes to strengthen clinical governance arrangements, and the identification of medication safety officers (MSOs) and multi-professional groups to review medication error incidents and improve medication safety locally.

  2. Prevent the spread of carbapenemase-producing Enterobacteriaceae

  3. ECGs are routinely performed to diagnose cardiac problems and there are no risks associated with the test itself, however, there is a risk of associating ECG records with wrong patients leading to misdiagnosis and incorrect treatment.

  4. This alert provides new guidance on spinal (intrathecal) devices for chemotherapy that replaces guidance in previous alerts NPSA/2009/PSA004A and NPSA/2011/PSA001. All other guidance in previous alerts remains unchanged.

  5. This alert has been issued in response to two recently reported patient safety incidents, when enteral nutrition was unintentionally given into the respiratory tract through a misplaced nasogastric tube inserted with the aid of a placement device.

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