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Patient safety alerts: Failing to reach the frontline

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Recent research has found that patient safety alerts are routinely not being implemented. Louise Hunt looks at the barriers that prevent the NHS learning from its mistakes

Patient safety alerts were introduced in 2004 in order to enable the NHS to learn from, and avoid repeating, potentially life-threatening mistakes. However, research commissioned by the Department of Health has found that these alerts are often not acted upon because staff caring for patients do not fully understand them - or do not see them at all.

Researchers from the universities of Cardiff and York tracked the progress of several alerts issued in 2006 and 2007 in more than 40 UK trusts. They found that, although the alerts got through to middle NHS managers effectively, there were problems in how the recommendations were distributed to, and interpreted by, frontline nurses. As a result, implementation by nurses was 'suboptimal'.

The safety alerts covered nasogastric tubes, latex allergy, needle-free intravascular connectors, alcohol-based handrub, mobile heated food trolleys, electrically operated beds, implantable cardiac defibrillators, radiotherapy, oral methotrexate and guedal airways. The researchers reported their findings and recommendations to the Department of Health last year and, in September of this year, they published the results of the implementation of three alerts - nasogastric tubes, latex allergy and needle-free
intra-vascular connectors - in the Journal of Advanced Nursing (see box).

Annette Lankshear, the lead researcher at the School of Nursing and Midwifery in Cardiff, says several barriers to learning from mistakes were identified.

'What we found was that trusts were slightly over-optimistic in their belief that alerts had been acted upon,' she says.

Lack of understanding

One of the main issues is that liaison officers - the people appointed to pass on the alerts - may not always know who to inform or fully understand the alerts.

Two-thirds of those interviewed had non-clinical backgrounds, although Ms Lankshear admits further research is needed to determine whether having a clinical background makes a significant difference. The clinical support they received varied enormously.

'In some trusts, there was really good support where liaison officers are practically welded to a chief nurse or patient safety manager who could advise them and, in others, they didn't have that support.

In some cases, inappropriate decisions were made,' she says. For example, the alert on nasogastric tubes required managers to 'provide staff, carers and patients in the community with information on correct and incorrect testing methods'. However, five of the 15 participating PCTs had not circulated the alert, deeming it to be irrelevant.

'In my view, every nurse in the country should have received this alert. They may be a district nurse today but they could be working in an acute ward tomorrow,' Ms Lankshear argues.

The way alerts are titled could also be a reason why nurses are not receiving the information they should. With needle-free intravascular connectors, 'the majority of trusts completely failed to recognise the importance of this alert because it was a phrase that didn't mean anything to them, even though it was a device used on almost every ward', Ms Lankshear says. On the wards, the devices are more commonly known as 'Bionectors' or 'bungs'.

In the case of the latex allergy alert, action appeared to have been taken because trusts introduced latex-free gloves. However, on further questioning, it became clear that nurses had not considered the possibility of patients having an allergy or that latex is contained in many other items, such as mattress covers or oxygen masks.

Nurses unaware

Nurses may not be aware of the alerts because ward and community nurse managers, most of whom receive alerts in electronic form, simply leave hard copy versions in folders for staff to read when time allows.

'The alerts may get down to ward manager level but staff might not get around to reading the communications folder. People are very busy. They are not looking for something to read,' she adds.

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The Department of Health has already made some changes in response to the findings but these have focused on the paper trail rather than on the transition of alerts into implementation. It has changed the way patient safety alerts are distributed by replacing the safety alert broadcast (SAB) system, which covered a range of clinical areas, with a central alerting system. This central system merges two DH alert systems - the public health link system and the SABs - to cover a wider variety of areas, in an attempt to improve clarity and access to alerts. The central alerting system has more sensitive search facilities and can be accessed on the internet.

The DH has also introduced a charting and reporting engine in order to analyse and monitor trusts' compliance with safety alerts. It makes the information gathered available to strategic health authorities, healthcare regulators and the trusts themselves.

The National Patient Safety Agency, one of the bodies that issues alerts through the central system, is working on ways to improve implementation of its alerts.

Suzette Woodward, NPSA director of patient safety strategy and nursing lead, concedes that in the past the agency 'has been too passive in the way alerts have been issued' and says that more work is needed to target nurses.

'I don't think we've said to nurses 'this applies to you'. What we have done is too generic by saying organisations should decide how patient safety recommendations should work locally, which is part of shifting the balance of power to trusts.

'But we've learnt that organisations do need help through guidance on how to implement change and that we can reach frontline staff if we provide support through their directors. It's about clearly working out who we're targeting and what would make them change, and providing support that makes that change real to them.'

The NPSA has also learnt that its alerts need to be communicated as simply as possible.

'We have realised that compliance is not as good as it could be and that anything we produce shouldn't just be a piece of guidance. It needs to have a clear explanation as to why behaviour needs to change, how long this should take and what is expected of nurses,' Ms Woodward says.

Nurse directors responsibilty

At the same time, nursing directors have a responsibility to inform staff of alerts, which also come via the chief nursing officer for England's bulletins. All too often, she says, 'anything labelled as 'patient safety' is quickly passed on to risk managers'.
'They should be taking ownership of disseminating information to line managers, preferably in meetings, who then need to help frontline staff to understand why changes have to be made.'

Why change is necessary is often not explained by managers to staff. Ms Woodward recalls one nurse who said she had not known why the cardiac arrest emergency phone numbers had been changed in her trust until Ms Woodward explained this had happened in all trusts to end the huge variation in systems.

Linda Watterson, the RCN programme manager for evaluating and improving, points out that, because the research shows a mixed picture, it is difficult to determine whether the same problems are an issue everywhere. However, it does highlight a need for nurses to review the penetration of patient safety information in their own organisations, she says.

'Everybody has a role in making sure alerts are implemented at every level. I would expect ward managers and team leaders to have an integral role in cascading information to colleagues,' she says.

She points to the finding in the latex allergy example that, in critical care areas where there was a higher than average awareness of the risks to patients, nursing champions had been appointed to ensure all their colleagues were aware of the alert. 'This is a good example of the kind of things nurses can do locally,' she says.

Latex allergy highlights the knowledge-practice gap

There is a consensus that progress can only be made with more robust monitoring. To this end, the Healthcare Commission has beefed up its approach to assessing the effectiveness of patient safety alerts. Last year, it introduced spot checks requiring evidence of implementation on randomly chosen alerts as part of its NHS health checks.

'We have strengthened the way in which we assess implementation of patient safety alerts because there is no nationally available data to enable us to know how well trusts are doing this,' says Maggie Kemner, head of safety at the commission.

The spot checks will be part of next summer's health check but it is not known whether they will be continued when the incoming Care Quality Commission introduces a new assessment system.

The current regulator is also undertaking research into how patient safety alerts are implemented and who is accountable for making changes, which will be published early next year. 'We are not aiming to find a best way - different trusts do things differently - but we would like to make sure from the feedback we get that the system for implementing alert recommendations is robust. We will be taking this learning to the new regulator,' she says.

Incentive

A further incentive for trusts to ensure implementation is to come from the NPSA, which has identified a set of preventable, but potentially catastrophic, events called 'never events'. If one of these occurs, it could result in trusts paying financial penalties for unsafe care. Reporting of 'never events' is due to start in 2009-2010.

Ms Lankshear believes that these tougher approaches to compliance are likely to make the biggest difference in raising the profile of patient safety alert implementation among trust managers.

'It's the monitoring of implementation that's important. At the end of the day, a policy has never saved anyone's life,' she says.

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