Identify if your organisation purchases blood control (closed system) safety cannula. If it does, for all clinical areas and teams likely to undertake needle thoracostomy, including ambulances, emergency departments (EDs), intensive care units, respiratory units or any unit providing invasive or non-invasive ventilation, including units for COVID-19 patients:

• Provide standard safety cannulas* for needle thoracostomy in appropriate trays, drawers, pockets, within emergency workspaces, emergency kit bags, and resuscitation trolleys, and clearly label ‘For use in tension pneumothorax’.
• Attach visible warnings/notices to cupboards, drawers, etc in these emergency workspaces, emergency kit bags, and resuscitation trolleys where blood control (closed system) cannula are stored stating: ‘Do not use for tension pneumothorax’, with a direction to where standard safety cannulas can be found.
• Amend labelling/checklists in store cupboards used to restock these resuscitation areas, emergency kit bags and resuscitation trolleys to ensure clear distinction between standard safety cannula and blood control (closed system) cannula.
• Inform clinical and materials management staff who restock these resuscitation areas, emergency kit bags and resuscitation trolleys of these changes.

Over a two-year period in England between July 2018 and July 2020, four deaths and four intensive care admissions were attributed to steroid omission, according to the NHS Improvement national reporting and learning system.

To prevent such incidents, the Society for Endocrinology, Royal College of Physicians, and NHS England’s patient safety team has developed an NHS steroid emergency card (SEC). This is a patient-held prompt that can be given to healthcare professionals when in crisis, or when undergoing a procedure to ensure steroid treatment is given appropriately and promptly. These cards should also be flagged up by hospital electronic systems and by patients in remote consultations.

A patient safety alert was issued alongside this, which requires general practice to take action by 13 May 2021. This includes assessing patients who are prescribed steroids and ensuring that all eligible patients are issued with an SEC.

Primary actions to be completed by 7 October 2020:

1. Identify and locate affected devices in your organisation.
2. Identify alternative ventilators available on site.
3. If no suitable alternative available, and capacity is an issue currently or expected imminently, follow protocol for resource shortage escalation set out by your local governance.
4. Train all relevant staff on alternative ventilators and ensure training records are up to date.
5. When actions 1–4 are complete, remove affected V60s from use and quarantine until repaired by the manufacturer.
6. Place the alternative devices into service in place of the affected V60s.
7. You may continue to use affected V60s if there is a risk of severe patient harm due to lack of ventilator availability. A thorough risk assessment must be completed, and additional monitoring must be used. A backup form of ventilation must be available at all times.

Secondary action to be completed by 23 December 2020:

           8. Review procurement and stock policies to ensure you are not reliant on one manufacturer or model of ventilator.

The alert asks providers to add clear labels to HFNO delivery devices to make staff aware that even brief interruptions to mains power supply could lead to respiratory and cardiac arrest; and that HFNO in any emergency department or short stay unit must not be started without a plan for how to transfer the patient onwards.

Where a UPS is used, action must be taken on the storage and maintenance of UPS devices to ensure they are ready for use and staff know where to locate them.

General practices:

• Practices using EMIS: If you have received a ‘task’ from EMIS identifying specific patients who have a record of a mechanical heart valve and are receiving a DOAC, and you have not already actioned this request, urgently review these patients to ensure they are on the most appropriate anticoagulation therapy and monitoring.
• Practices using TPP: If you have received a ‘task’ from TPP identifying specific patients who have a record of a mechanical heart valve and are receiving a DOAC, and you have not already actioned this request, urgently review these patients to ensure they are on the most appropriate anticoagulation therapy and monitoring.
• Practices using other GP system software: If your practice does not use EMIS or TPP software, urgently review all patients with a mechanical heart valve to ensure they are on the appropriate anticoagulant therapy and monitoring.

Providers of anticoagulation services:

• Urgently check patient records from January 2020 to identify any patient with a mechanical heart valve who has been switched from a VKA to an alternative anticoagulant.
• For identified patients you should either: (i) Urgently review these patients if still under the care of the service to ensure they are on the appropriate anticoagulant therapy and monitoring or (ii) Work with the patient’s GP to ensure the patient receives an urgent review.

1. Identify if the accidental ingestion of dry thickening powder has occurred, or could occur, in your organisation.
2. Consider if immediate action needs to be taken locally, and ensure that an action plan is underway if required, to reduce the risk of further incidents occurring.
3. Distribute this alert to all relevant staff who care for children or adults in primary care, emergency care, and inpatient care settings, including mental health and learning disability units.
4. Share any learning from local investigations or locally developed good practice resources by emailing patientsafety.enquiries@nhs.net.