How should your practice respond to information you receive that might have an impact on the safety of patients?
Practices need systems and processes to communicate and act on patient safety issues and information. This includes information from external sources that could affect patient safety.
Sources of information include:
- National Patient Safety Alerts
- Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts (medicines recalls, notifications and devices safety information)
- UKHSA Urgent Public Health Messages Central Alerting System (CAS) alerts. See the CAS website
- national and local formularies
- local or national clinical guidance.
Receiving and sharing information
Practices should:
- consider who should receive alerts within the practice
- make sure there are effective processes to act on alerts received
- arrange cover for planned and unplanned staff absences to ensure you review and act on all alerts as soon as possible.
You could keep a log of alerts and document action taken in response to these.
Your practice needs to be registered with the Central Alerting System (CAS).
All safety alerts that need action by healthcare organisations will be issued as National Patient Safety Alerts.
Alerts are created using a set template, following criteria agreed by the National Patient Safety Committee.
This is to ensure that National Patient Safety alerts:
- are only issued for safety-critical issues (those that have a risk of death or disability) that need organisations to act on them
- explain risk clearly and effectively
- have required actions that have been assessed for feasibility, safety, efficacy and cost-effectiveness
- can be quickly recognised and actioned by senior personnel
- have actions that are SMART (specific, measurable, achievable, realistic and timely).
There are changes to some safety communications that do not meet the National Patient Safety Committee criteria. These are highlighted on the CAS website.
MHRA’s monthly drug safety update provides information for healthcare professionals covering the safe use of medicines. If your practice does not receive this directly, you should register on the MHRA website.
Acting on alerts
To monitor updates and alerts and act on these in a timely way, you practice should have:
- systems to identify, recall and follow up with patients who are affected
- a process to recall a medicine or device
- prescribing advice incorporated into routine clinical practice, in the same way as any other prescribing guidance. This could be through medicine reviews or as part of the practice audit programme.
Many practices use technology to monitor and raise alerts to facilitate ongoing safe prescribing.
As well as acting on alerts, healthcare providers also have a duty to report any adverse incidents relating to medicines and devices using the Yellow Card Scheme.
Example
This is an example of a safety alert that may be relevant to a dental practice. The practice must check that the information it refers to is up to date.
What we look at
We use these regulations when we review whether the practice is safe, effective, caring, responsive and well-led.
When we look at the management of safety alerts, we use:
Our assessment will include:
- ensuring providers are receiving and acting on relevant National Patient Safety Alerts and safety messaging
- checking that relevant practice staff are aware of the alert, including the most recent updates and of the risks relating to medicines
- reviewing the action taken to make sure affected patients have been identified, contacted and reviewed. This may include checking a sample of patient records
- reviewing arrangements in place to check that relevant actions are complete and checking that no new patients affected have joined the practice.