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
Anticoagulation and Head Injury 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
Phenol – wrong strength – Signal
Sedation – over sedation in emergency procedures – Signal
Skin preparation and fire risk – Signal
Vaccine storage – Signal
Vernagel ingestion – Signal