Archived Patient (Medication) Safety Alerts from the NPSA and SPS resources to support their implementation

Nicola Wake, Medication Safety Officer Lead, Specialist Pharmacy ServiceSource Medicines Use and Safety Team and UKMiPublished
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These pages bring together all the patient safety alerts that relate to medications that were published between 2002 and 2012 by the National Patient Safety Agency (NPSA).  Some alerts have at different points in time also become Never Events – information can be found on Department of Health website

All patient safety alerts issued since 2012 can be found on the NHS Improvement (NHSI) homepage.

Between 2002 and 2012 patient safety alerts were issued by the National Patient Safety Agency (NPSA) – the NPSA website was archived in 2012 but it has been  available here.  Please use any material at those links with caution.  NPSA Alerts were only updated to reflect changes in current safety knowledge or clinical care until the point their ‘action complete’ date was reached.  Some of these ‘action complete’ dates for NSPA Alerts, Safety Notices and Rapid Response Reports are now over fifteen years in the past, and no NPSA publications have been updated since the closure of the NPSA in 2012.  Alerts issued between October 2008 and March 2012 can also be found on the Central Alerting System (CAS) website (Search for Alerts issued by the NPSA).

The NPSA also supported Signals – Key risks emerging from the review of serious incidents reported by the NHS to its National Reporting and Learning System (NRLS) were shared between September 2009 and February 2012.  The archived NPSA website is currently still accessible and all the Signals issued can be found here .   The issues raised in NPSA Signals are still current. 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.

Details of the medication related alerts can be found in the links below (click on the word alert for the relevant alert you are interested in).  Where the SPS Medicines Use and Safety Team and/or UKMi  have developed specific resources to support the implementation of an alert – a link is provided via the word resources for the relevant alert.

The alerts are listed by drug or system alphabetically rather than in chronological order.  A  chronological list is attached below.

Amphotericin – lipid and non-lipid formulations – alert

Anti-cancer medicines -oral – incorrect dosing – alert 

Anticoagulants – oral – making safer – alert and resources

Bowel cleansing – alert

Cytarabine – confusion liposomal and non-liposomal – alert 

Epidural injections and infusions – alert

Gentamicin in neonates – alert 

Heparin flushes – alert

Hib-vaccine omission – alert

Infusion Device safety  – alert

Infusion fluids in neonates – reducing risk of hyponatraemia alert and over infusion –  over-infusion alert  

Injectable medicines – promoting safer use (NPSA 20)  – alert and resources

Insulin passport and safer administration – alert safer administration, alert insulin passport and resources

Latex – protecting people with allergy to – alert

Liquid medicines – safer measurement and administration – alert

Lithium – safer therapy – alert

Loading doses – prevention of fatalities – alert and resources

Low molecular weight heparins – dose errors – alert 

Medicines Reconciliation alert and resources

Methotrexate – oral guideline compliance – alert 

Midazolam overdose – alert 

Omitted and delayed medicines – alert and resources and resource 2

Opiate themed alerts (high dose morphine and diamorphine and dosing errors/reducing dosing errors) – alerts 2

Oxygen safety alert and resources

Paraffin based skin products – risk of fire – alert

Potassium solutions – risks during IV preparation and administration – alert 

Repevax and Revaxis vaccines – alert 

Spinal, epidural and regional connectors and devices – mismatching and safer devices –  alert and resources  alert neuroaxial connectors

Syringe drivers (ambulatory) – alert

Vaccine cold storage – alert

Vinca alkaloid mini-bags – alert