Patient safety

Supporting the care of patients with acute kidney injury

A stage two alert has been issued to support NHS providers in diagnosing, treating and managing acute kidney injury. Resources to support the care of patients with acute kidney injury This alert has been issued to raise awareness of acute kidney injury (AKI) and to signpost clinicans to a set of resources developed by Think Kidneys. These resources […]

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Nasogastric tube misplacement: continuing risk of death and severe harm

A stage two alert has been issued to support providers of NHS-funded care to prevent the risk of severe harm or death caused by the misplacement of nasogastric tubes (NG tubes). Nasogastric tube misplacement: continuing risk of death and severe harm This alert highlights patient safety incidents involving the misplacement of nasogastric and orogastric tubes. […]

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Supporting safer care where patients are deteriorating (adults and children)

A stage two resource alert has been issued to support the timely identification, response and management of the deteriorating patient (adults and children). Resources to support safer care of the deteriorating patient (adults and children) Related content Patient safety alerts A safe system framework for recognising and responding to children at risk of deterioration Resources […]

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Patient safety incident reporting and responding to patient safety alerts

A stage two resource alert has been issued around patient safety incident reporting and responding to patient safety alerts. Patient safety incident reporting and responding to patient safety alerts On 1 April 2016 the statutory patient safety functions previously delivered within NHS England transferred to NHS Improvement. These functions are the responsibility for: operating the […]

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Prioritisation of general practice home visits

A stage one warning has been issued around the prioritisation of general practice home visits. Risk of death from failure to prioritise home visits in general practice When a request for a home visit is made, it is vital that general practices have a system in place to assess: whether a home visit is clinically necessary […]

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Patient safety alert – Risk of severe harm or death when desmopressin is omitted or delayed in patients with cranial diabetes insipidus

A patient safety alert has been issued by NHS England to raise awareness of the risk of severe dehydration and death caused by an omission or delay of desmopressin in patients with cranial diabetes insipidus. Cranial diabetes insipidus is a rare disorder of the pituitary gland characterised by an inability to produce antidiuretic hormone (ADH), […]

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The risk of using different airway humidification devices simultaneously

A stage one alert has been issued to raise awareness of the risk of having two different types of airway humidification devices simultaneously connected to a patient’s ventilation equipment. The risk of using different airway humidification devices simultaneously There are two humidifiers in common use: heated (water) humidifiers (HHs), usually located between the ventilator and […]

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