Patient safety alerts that are sparked by avoidable deaths are being routinely ignored, a charity has found after making a freedom of information request.
Data obtained by charity Action against Medical Accidents shows that only two of the 57 safety alerts issued by the National Patient Safety Agency since 2004 have been complied with by every trust in England.
The real acid test of implementation is how well the changes are cascaded down to people who need to know, such as nurses
The alerts, which include the more urgent rapid response alerts, require specific action to be taken by a certain date.
Sixty-three per cent of trusts had failed to comply with at least one alert, and 29 trusts had not complied with 10 or more by the time the deadline for implementation had passed.
Alerts include, for example, safe use of bedrails, safe practice with epidural injections and implementing systems to make sure patients receive the correct blood.
All trusts and other NHS organisations have a responsibility to report to the Department of Health’s central alert system that they have implemented the alert’s requirements or that it is not relevant to them.
Action against Medical Accidents conceded that some trusts may have complied with the alerts yet not notified CAS, but said it was also “very likely” that some trusts may have claimed compliance without implementing the changes required.
Chief executive Peter Walsh told Nursing Times that many of the alerts required work that would affect nurses.
“In some ways, our research is quite simplistic. The real acid test of implementation is how well the changes are cascaded down to people who need to know, such as nurses,” he said.
The figures show more than 1,200 patient safety alerts were not complied with across the NHS in England. The organisations with the highest rates of non-compliance were Walsall Teaching PCT (23 alerts); Sandwell Mental Health and Social Care Foundation Trust (21); Worcestershire Acute Hospitals Trust (20); and York Hospitals Foundation Trust (20).
The Care Quality Commission said trusts were not ignoring safety alerts and, in “most cases”, had demonstrated they had taken significant action. But it is scrutinising all trusts’ responses and will act if there is any cause for concern and publish its findings.
Sandwell Mental Health and Social Care Trust said just 14 alerts issued since 2004 related to mental health trusts. It has informed the CQC of administration problems with its alert reporting system.
Worcestershire Acute Hospitals Trust chief executive John Rostill said the trust had 16 open alerts, all of which he had reviewed personally.
York Hospitals Foundation Trust said it had an “action plan” to address alerts.