Archived NPSA Signals – Emerging issues from national review of serious patient safety incidents 2009-2012

Nicola Wake, Medication Safety Officer Lead, Specialist Pharmacy ServiceSource Medicines Use and Safety TeamPublished
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Signals | Emerging issues from national review of serious patient safety incidents

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.

The archived NPSA website is currently still accessible and all the Signals issued 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 is shared as Signals. The last set of Signals was issued 28 February 2012.

The medicines related NPSA Signals are listed alphabetically below by drug or system (a chronological list is attached).

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

Alphabetical list of NPSA Signals relating to medicines: click on the word Signal to see details.

Alfacalcidol – prevention of harm – Signal

Anaesthesia – Residual anaesthesia in cannulas Signal & Total anaesthesia – Signal

Anticoagulation and Head Injury Signal 

Extravasation in Neonates Signal & Revisted Signal 

Injectable Medicines – In Theatres Signal & – Multiple Use of Single Use products – Signal

Intravenous Connectors in Neonates – Signal 

Midazolam (Buccal) – Signal 

Morphine in neonates – Signal 

Neonatal resuscitation – Signal

Pain relief in terminally ill in the community – Signal

Paracetamol Overdose – Signal & Intravenously in Children and Infants Signal

Phenol – wrong strength – Signal

Sedation – over sedation in emergency procedures – Signal 

Skin preparation and fire risk – Signal

Vaccine storage – Signal

Vernagel ingestion – Signal