ABSTRACT
AIM: This paper is a report of a study to determine whether action required by patient safety alerts was effectively taken. BACKGROUND: Over the last 10 years, there has been a growing awareness of the number of patients unintentionally harmed in the course of their treatment. Safety alerts are designed to reduce the incidence of adverse events by removing these predisposing factors. METHOD: A multi-method study was carried out in 20 acute, two mental health, four ambulance and 15 primary care provider organizations in the United Kingdom in 2006-2007 using surveys, interviews with senior managers and front-line staff, collection of documentary evidence and equipment audit. The implementation of three safety alerts for nursing action is reported. FINDINGS: Most staff were aware of the dangers posed by gloves to staff with latex allergy, but only 20% were aware of the types of common equipment that posed a danger to sensitive patients. Almost 40% of nurses were unable to give a correct acidity value to allow nasogastric feeding to commence. One alert, on needle-free intravascular connectors, was distributed in only a few organizations as the term used was unfamiliar at all levels of the organization. CONCLUSION: Healthcare providers have succeeded in setting up successful systems to disseminate alerts to middle management level, but there is evidence that implementation of recommendations by nurses is sub-optimal.
