The names of organisations that fail to comply with patient safety alerts are to be published online each month as part of a revamped warning system being introduced by NHS England.
The patient safety alert system is being upgraded to spread information about emerging concerns throughout the health service more quickly, in response to recommendations of the Francis report and the Berwick review into patient safety.
The previous system was operated by the National Patient Safety Agency, which was abolished in 2011.
NHS England’s national director of patient safety Mike Durkin told HSJ that whereas the agency used to take “months” to issue alerts, NHS England intended to be more responsive. It will consult expert patient safety groups on whether to send out an alert, rather than setting predetermined criteria.
Dr Durkin said: “It’s best to take every emerging risk on its own merit. One of the lessons learned from around the world is it’s only by triangulating and bringing together whole system approaches to reporting do you start to match that an emerging risk is popping up across the whole piece.”
The Mid Staffordshire Foundation Trust public inquiry heard evidence that almost two thirds of trusts had one or more outstanding patient safety alert. However, it is thought compliance could be even lower as some trusts incorrectly claimed to have implemented actions to address concerns.
Under the new three stage system, a stage 1 alert will be issued to ensure emerging concerns are shared as soon as possible with providers. This will be followed soon after by a stage 2 “resource” alert, with more in-depth information and advice on dealing with the issue.
Finally, a stage 3 “directive” alert will be issued, setting out what actions providers must take to mitigate the risk.
The first stage 1 alert, on the use of placement devices for nasogastric feeding tubes, was issued in December, within five days of the second of two incidents - in which enteral nutrition was inserted into the respiratory tract - being reported to the National Reporting and Learning System.
Stage 3 alerts specifying how organisations should handle reporting of medication errors and medical device incidents are currently the subject of a consultation, as is an alert specifying the types of devices that should be used to deliver intravenous chemotherapy.
Providers, including GP practices, must declare to their commissioners that they are compliant, while NHS England is also working with the CQC to incorporate monitoring of compliance into its regulation of providers.
Asked how this would ensure greater levels of compliance than under the previous system, Dr Durkin said commissioners would be “actively involved” in the alerts, including checking “whether or not the actions have taken place”. He said he anticipated NHS England issuing a similar number of alerts to the NPSA, which had a rate of about 12 a year.
The revamped alert system is one of a number of patient safety actions NHS England has taken in the wake of the Francis report. Last week, its board confirmed funding of £12m a year for the next five years to support the creation of 15 patient safety collaboratives and 5,000 patient safety fellows.
Chief nurse Jane Cummings told the meeting a “sustainable and statistically significant reduction in patient harm [needed to be delivered] by autumn 2015”.
The collaboratives should be up and running by the end of 2014-15, based on the boundaries of academic health science networks. They will be required to focus on pressure ulcers and medication errors in the first instance.