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Implementing national patient safety alerts

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National patient safety alerts must be implemented if risk to patients is to be reduced. Trusts should explore the barriers to implementation to effect bottom-up change


National patient safety alerts are sometimes difficult to implement in an effective way. All trusts have to declare compliance with alerts as part of a three-step process to improve patient safety. This article discusses an alternative way of implementing national patient safety alerts and describes how behaviour-change methods can be used to successfully implement lasting changes in practice at ward or departmental level.

Citation: Moore S et al (2016) Implementing national patient safety alerts. Nursing Times; 112: 11, 12-15.

Authors: Sally Moore is patient safety research nurse at Bradford Institute for Health Research; Natalie Taylor is a senior research fellow at the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia; Rebecca Lawton is professor of psychology of healthcare, University of Leeds, and director of the Yorkshire Quality and Safety research group; Beverley Slater is director of the Improvement Academy, Yorkshire and Humber Academic Health Science Network.


Patient safety should always be high on the list of priorities for nurses. Operating outside of national guidance that is endorsed by employers can leave nurses in a very vulnerable position should an incident occur. Nurses have a responsibility to patients, employers and their professional body to deliver safe care (Nursing and Midwifery Council, 2015), but this can be difficult when guidance for care delivery is complicated or hard to manage.

Human factors are all the factors that can influence people and their behaviour. In a work context, environmental, organisational and job factors, as well as individual characteristics, influence behaviour (Carthey and Clarke, 2010). Sometimes the human factors involved in designing and implementing guidance into healthcare practice – such as education, notices, audits and emails – can result in less than 50% of staff following clinical guidelines (Michie et al, 2005).

The psychology of human error can account for some non-compliance, but it can often be staff doing what they know to be the “wrong thing” for the “right reasons” that leads to non-compliance and, on occasion, error (Carthey and Clarke, 2010). For example, if a nurse knows that a patient has run out of prescribed intravenous fluid and no one is available to prescribe more, they might commence another bag of fluid and ask a doctor to write the prescription later, leading to non-compliance with protocol and increasing the risk of the wrong type or dose of intravenous fluid.

Last year (2014/15), the Clinical Negligence Scheme for Trusts, managed by the National Health Service Litigation Authority, managed 588 claims linked directly to nursing care; this was at a cost to the NHS of just under £500,000 (NHSLA, 2015).

So how can we support staff to do the “right thing” for the “right reasons”, thereby preventing untoward incidents, harm and cost to patients, staff and the health service?

Box 1 describes the reflections of one nurse’s experience of trying to do the right thing for the right reasons.

Box 1. Implementing alerts in practice

A nurse tells of her experience of trying to do the “right thing” for the “right reasons”:

“Working as senior nurse in a busy district general hospital, often my desk became home to National Patient Safety Agency alerts; I was the person responsible for ensuring that practice in my departments met the requirements of the alerts.

“This could be a relatively easy process, for example, ensuring we did not use certain items of equipment, or withdrawing supplies from circulation. But it could sometimes be very complicated, involving a multidisciplinary team and requiring changes in practice for staff that could not see any logical reason to change, as they had never experienced an adverse event with the practice in question during their career.

“Trying to find ways of implementing the more complicated patient safety alerts is difficult. Sometimes the solution is the development of an evidence-based guideline that meets the requirements of the alert and is agreed by the trust for implementation. These alerts rarely include any indication of how they would be shared with staff for use in practice or any tools to measure compliance, so there is often no way of knowing whether the action to implement the alert has been successful. It was this way of managing the alerts that sometimes left me unsure of how well we were actually implementing change.

“I believe that while my colleagues and I managed the alerts well, we very rarely checked to see whether a change in practice had actually happened.”

A new approach

The Yorkshire Quality and Safety research group recently worked with trusts in West Yorkshire on a service improvement project aimed at challenging current ways of implementing patient safety alerts and guidelines. This new approach moves away from imposing guidelines on staff (that is, top-down change); instead, it uses an evidence-based approach to identify issues locally and develop interventions that target identified barriers to behaviour change (bottom-up change) (Taylor et al, 2014).

The method requires a dedicated team to spend time working through the implementation process, but it has been shown to deliver measurable and sustainable change if the correct process is followed and the right people are involved (Taylor et al, 2014; Taylor et al, 2013a). The implementation process will not work unless there is support and willingness to make change happen from both senior management and frontline staff.

Good practice


Frontline staff, including junior doctors and nurses, collaborated with behaviour change and patient safety specialists in a trust to support the implementation of the 2011 National Patient Safety Agency (NPSA) nasogastric tubes alert; this was issued when it became clear that several trusts had not fully implemented a safety alert issued in 2005, and that subsequent alerts and a rapid response report were also not being implemented (Box 2). An evidence-based framework of behaviour change – the Theoretical Domains Framework implementation approach (Taylor et al, 2013b) – was used to:

  • Identify key behaviours of concern within the trust;
  • Examine individual-level barriers to change that were preventing the desired behaviours;
  • Devise locally tailored strategies with staff to overcome these barriers.

A full description of the study and methods is discussed elsewhere (Taylor et al, 2014; 2013a; 2013b).

Barriers to compliance with the NPSA’s 2011 nasogastric tubes alert were assessed by a multidisciplinary group of 99 hospital staff members, who agreed to complete a patient-safety-practices questionnaire. This was designed using a theoretical framework of behaviour change (Taylor et al 2013b; Michie et al, 2005) comprising the following domains:

  • Knowledge;
  • Skills;
  • Social and professional identity;
  • Beliefs about capabilities;
  • Beliefs about consequences;
  • Motivation and goals;
  • Cognitive processes;
  • Memory and decision-making;
  • Environmental context and resources;
  • Social influences;
  • Emotion;
  • Action planning.

Two multidisciplinary focus groups were held with staff to elicit more detailed information about those barriers reported most frequently by questionnaire respondents. These groups, guided by the expert knowledge of the project team, were then used to identify intervention strategies.

Box 2. Slow response to a patient safety alert

  • February 2005: National Patient Safety Agency (2005) states there were “11 deaths and one case of serious harm due to misplaced nasogastric feeding tubes over a two-year period”. Patient Safety Alert 05 is issued.
  • March 2011: NPSA (2011) is aware of “a further 21 deaths and 79 cases of harm due to feeding into the lungs through misplaced nasogastric tubes” since issuance of the 2005 NPSA alert. Patient Safety Alert NPSA/2011/PSA002 is issued, reiterating the recommendations of the 2005 alert and actions for health professionals.
  • March 2012: NPSA issues rapid response report NPSA/2012/RRR001 (NPSA, 2012).
  • December 2013: NHS England issues NHS/PSA/W/2013/001 alert (NHS England, 2013). These documents focus on placement devices and the flushing of nasogastric tubes; both reiterate the recommendations of the 2005 alert.
  • 2013 onwards: Adverse events are still happening. The never-event data from NHS England shows 16 incidents of misplaced oral or nasogastric tubes between 1 April 2013 and 31 March 2014 (NHS England 2014b), and 10 events between 1 April 2014 to 31 March 2015 )NHS England, 2015).
  • Provisional data for 2015/16 to the end of December 2015 (NHS England 2016b): Data shows 31 incidents of a misplaced oral or nasogastric tube.

Pre-intervention audit

To be able to assess the extent of the problem and to measure current practice, an audit was undertaken of staff behaviour when checking the placement of nasogastric tubes against the NPSA’s 2011 alert. It was clear from this initial audit that X-ray was mainly used as the first-line method for checking tube position (49% of cases); pH testing was used as the first-line method <18% of the time. As the alert requires pH testing to be the first-line check, the team decided to focus on identifying the barriers to using pH as the first-line method for checking tube position.

The four strongest barriers to using pH as a first-line method for checking tube position were found to be:

  • Social influences (influence of peers, seniors);
  • Belief about capabilities (necessary understanding and skills to check pH first line);
  • Environmental context and resources (equipment, systems, communication levels);
  • Emotion (fears and anxieties associated with performing the desired behaviour).


Having identified the key barriers to using pH testing as the first-line check, information from the focus groups allowed us to begin to design tailored interventions in partnership with staff, who would address them. These included:

  • The development of a nasogastric tube e-learning package and provision of practical training to equip staff with the necessary knowledge and skills to comply with the alert;
  • The development of posters and screensavers, which explicitly targeted the identified barriers of social influence and emotion through key pictures and messages;
  • Presentations given at clinical governance meetings for senior staff, which aimed to address knowledge and social influences;
  • Implementing radiology system change and designing documentation to address environmental context and resource barriers.

All of these interventions were used as part of a strategy to target and address the specific barriers that had been identified for those staff in that specific hospital context.

Post-intervention audit

A post-intervention audit demonstrated that pH was the predominant first-line method for checking position (62.5% of cases), with X-ray being used as the first-line check in only 23% of cases. This represents a clear improvement in practice, moving in the direction of the alert’s recommendation.

Fig 1 (attached) shows the results of the 18-month retrospective casenote review, highlighting the points at which the following interventions were used to increase the use of pH testing as the first-line method for checking tube position:

  • March 2011; revised NPSA (NPSA/2011/PSA002) alert released;
  • June 2011; new trust documentation launched;
  • September and October 2011; the project was presented at four clinical audit meetings;
  • October 2011: foundation year 1 doctors attend mandatory nasogastric tube placement training;
  • February 2012: screensaver launched with an awareness day; radiology system change introduced.


By using a behaviour-change approach, we were able to:

  • Identify specific behaviours that were in need of change;
  • Identify the root of the problem by assessing barriers;
  • Tackle specific barriers using behaviour-change methods and work with staff to design and implement interventions;
  • Demonstrate improvement.

The post-intervention audit and the annotated run chart derived from the retrospective casenote review demonstrated the impact of the interventions on behaviour.

The collaborative nature of this work has enabled shared learning between health practitioners and behaviour change/patient safety specialists. The project supported multidisciplinary team-working, and improved understanding and communication between the professional groups; this can only strengthen patient safety across an organisation (Thomas, 2011). It also highlighted the need for a strong facilitator to drive the process forward to success.

Changes to the alerting system

In January 2014, NHS England (2014a) launched the National Patient Safety Alerting System (NPSAS), which has now taken over from the NPSA. This launch was part of the government’s response to the Francis report (2013), aimed at providing a clearer framework to support organisations to respond and act on patient safety issues.

The new NPSAS uses a three-stage system (Box 3), which has been developed to allow a more rapid response to incidents that could be potentially harmful to patients. It is managed through a central alerting system sign-off process, in which trusts are expected to confirm, usually at board level, that all actions presented in the alert have been addressed.

NHS England has already started making data publicly available via its website, naming trusts that do not declare compliance with any stage of an alert by the completion deadline date. The data is now available to the public and health service regulators. Currently, 15 trusts have not declared compliance to five alerts (NHS England, 2016a); six trusts have the implementation of an alert ongoing; five trusts are assessing the relevance of an alert to their practice; three trusts have only acknowledged an alert with a compliance date of January 2016; and there is one alert that is already past its compliance date that has not yet been acknowledged by one trust.

A system that relies on self-compliance will always have weaknesses. As an example, some hospitals might not state compliance, despite great efforts towards improvement, if they do not feel they have adequately met every action on the alert, whereas others might indicate compliance, without having robust evidence that they have fully achieved the recommendations.

Box 3. NPSAS stages

The three stages of the National Patient Safety Alerting System are:

  • Stage-one alert - Warning: identifying emerging risk and needing sign-off within specified timeframes from organisations
  • Stage-two alert - Resource: issued weeks or months after the warning, containing guidance for actions and also needing sign-off within a specified timeframe
  • Stage-three alert - Directive: needs confirmation within a specified timeframe from organisations that they have taken action to implement solutions minimising the risk

Source: NHS England (2014a)


To keep our patients safe and to “practise effectively” (NMC, 2015), nurses need to be aware of, and comply with, both local and national guidelines. To help staff deliver safe, high-quality care and work within guidelines, managers need to make sure nurses collaborate with them to develop guidance that can work in practice and has measurable outcomes.

The case study presented here shows that effective improvement in practice can be made if time and effort to get it right is put in with, and on, the “shop floor”. It also illustrates that we can evidence that we did get it right. Using these methods may mean putting in more time and effort but breaking down the barriers is a way to support lasting changes in practice when it really matters.

Key points

  • Health professionals must be aware of patient safety alerts
  • Local and national guidelines should be adhered to at all times
  • Health professionals should collaborate to find ways of implementing national guidance
  • Disseminating a guideline does not mean it will always be complied with
  • Health professionals should monitor their practice against measurable standards
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