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
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
Latex – protecting people with allergy to – alert
Liquid medicines – safer measurement and administration – alert
Lithium – safer therapy – alert
Low molecular weight heparins – dose errors – alert
Methotrexate – oral guideline compliance – alert
Midazolam overdose – alert
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
Syringe drivers (ambulatory) – alert
Vaccine cold storage – alert
Vinca alkaloid mini-bags – alert