Protecting patients from harm
identified using our reporting system to spot emerging patterns at a
national level, so that appropriate guidance can be developed and issued
to protect patients from harm.
Patient safety alerts are issued via the Central Alerting System (CAS), a web-based cascading system for issuing alerts, important public health messages and other safety critical information and guidance to the NHS and other organisations, including independent providers of health and social care.
We issue three types of alerts:
- Warning Alerts
Typically issued in response to a new or under-recognised patient safety issue with the potential to cause death or severe harm. We aim to issue warning alerts as soon as possible after becoming aware of an issue and identifying that healthcare providers could take constructive action to reduce the risk of harm. Warning alerts ask healthcare providers to agree and coordinate an action plan, rather than to simply distribute the alert to frontline staff.
- Resource Alerts
Typically issued in response to a patient safety issue that is already well-known, either because an earlier warning alert has been issued or because they address a widespread patient safety issue. Resource alerts are used to ensure healthcare providers are aware of any substantial new resources that will help to improve patient safety, and ask healthcare providers to plan implementation in a way that ensures sustainable improvement. Highlighted resources will usually have been developed by national bodies, professional organisations or networks.
- Directive Alerts
Typically issued because a specific, defined action to reduce harm has been developed and tested to the point where it can be universally adopted, or when an improvement to patient safety relies on standardisation (all healthcare providers changing practice or equipment to be consistent with each other) by a set date.
While most alerts will relate to patient safety issues, we also issue alerts that are aimed at improving local systems and processes for improving patient safety.
Alerts issued prior to 1 April 2012 are available via the archived National Patient Safety Agency (NPSA) website
Please note: The past NPSA alerts and guidance that remain available on the archived NPSA website should be used with caution.
NPSA alerts were only updated to reflect changes in current safety knowledge or clinical care until the point their ‘action compete' date was reached. Some of these ‘action complete' dates for NPSA alerts, safety notices and rapid response reports were over 15 years ago. No NPSA publications have been updated since the closure of the agency in 2012, with the exception of key actions still relevant to the Never Events policy and framework.
National Patient Safety Response Advisory Panel
The panel discuss and advise on approaches to respond to patient safety issues we identify from a range of sources. These sources include clinical review of incidents reported to the National Reporting and Learning System and Strategic Executive Information System, concerns raised by patients, the public and healthcare professionals, and coroner letters.
Where it is agreed the best course of action is to issue a patient safety alert, the panel will also provide advice on the contents of the alert. The panel will initially run as a six month pilot with opportunities for ongoing evaluation.