National Patient Safety Alerts: An Exploration of How Trusts Coordinate their Responses

There is emerging interest in how National Patient Safety Alerts (NPSAs) may be optimised amid recognition that the provision of information alone may be insufficient to change Trust practices. Following discussions between NHS Improvement and Yorkshire and Humber Patient Safety Translations Research Centre (PSTRC), exploratory work was undertaken by PSTRC researchers as a basis for a future research agenda. This included a document analysis of publicly-available Trust documentation in a region of England to explore how NPSAs are covered by Trusts. Informal stakeholder conversations were then undertaken to supplement the document analysis to provide a fuller picture.

The exploration reveals highly elaborate networked arrangements for managing NPSAs at Trust-level which national policymakers must navigate in their efforts to improve NPSAs. A top-down, regulatory approach should be avoided as that might unsettle existing networks and relationships. Yet, there is sympathy with the challenge confronting policymakers as local actors recognise that some Trusts have inadequate processes. Future research should seek to establish what roles, processes and relationships are required to secure effective responses. Understanding of where errors can arise, what Trusts currently do to manage them and how all Trusts might be supported to achieve best practice would be helpful.