Researchers interviewed staff in 41 trusts about the effect of three National Patient Safety Agency alerts. Two-thirds of ward managers recalled receiving them and over half made printed copies for staff.
One alert urged trusts to provide latex-free equipment and identify patients with latex sensitivities but the message did not always filter down.
Although all nurses knew the dangers to staff from latex allergy, only 20% were aware of the risks to latex-sensitive patients from commonly used healthcare equipment.
Less than half of nurses knew that latex-free oxygen masks were available on their ward, and many assumed that any equipment issued must be safe.
Despite an alert on nasogastric feeding, nearly 40% of nurses were unable to give a correct acidity value for feeding to begin.
A third alert, on needle-free intravascular connectors, was not well distributed to staff, partly because a legal challenge from the manufacturers had prevented the word ‘infection’ being used in the document.
‘Many nurses are missing or being denied the opportunity to learn from adverse events, including deaths that have occurred in other parts of the NHS. As a result they are failing to protect patients,’ the study authors concluded.