ARCHIVED NPSA Signal – The risk of harm when using intravenous connectors in children and babies – February 2011

Nicola Wake, Medication Safety Officer Lead, Specialist Pharmacy ServiceSource Medicines Use and Safety Team Published
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Key risks emerging from the review of serious incidents reported by the NHS to its National Reporting and Learning System (NRLS) were shared in in the form of Signals through the National Patient Safety Agency (NPSA) between September 2009 and February 2012.  The NPSA ceased to exist as an organisation in 2012 and NHSI now has responsibility for patient safety. 

SPS has created a page on the SPS website of all the medicines related Signals and where SPS Teams have produced resources to support reducing these risks these are linked. A link to the page can be found here.

At the time the Signals were issued the NRLS  held over six million patient safety incidents, which were reported from across the NHS in England and Wales. Staff at the NPSA reviewed each reported incident of patient death or severe harm – around 350 every week.

From the reviews, around ten alerts a year were produced. These require actions by NHS organisations to reduce risks to patients. However, there is much rich learning in addition to alerts and this was shared as Signals. The last set of Signals was issued 28 February 2012.

A link to the page on the SPS website about NPSA Alerts and the resources SPS have developed to support their implementation can be found here