National Patient Safety Agency: combining stories with statistics to minimise harm

In a busy endoscopy clinic, you draw up part of a high strength midazolam ampoule and realise that you have oversedated the patient. The patient has been harmed. What stops you reporting it? What would prevent it from happening again in your trust or elsewhere?

An article about avoiding midazolam overdose is the first in a series of BMJ summaries of recommendations to improve patients’ safety, based on reports of safety concerns, incident analysis, and other evidence.1 The midazolam article is from the National Patient Safety Agency (NPSA) in England and Wales, which each week receives reports from healthcare professionals of serious incidents that have the potential for serious harm.2 This article is a summary of the agency’s rapid response report (RRR) on midazolam overdose. RRRs are one-page notices with clear recommendations for actions that will reduce risks to patients, issued to all relevant NHS organisations in England and Wales, from hospitals to primary care organisations (www.nrls.npsa.nhs.uk/resources/type/alerts/).

Previous national safety interventions took time to develop3 and proved challenging to implement.4 And so over the past two years, the NPSA has developed RRRs as more timely alerts to staff about new or under-recognised risks. The trigger for an RRR is reported deaths or serious events that may be seen as “one-off” events by local organisations but which at a national level indicate to the agency that system weaknesses exist for which fixes are available that could benefit all trusts. RRRs are issued in England through the Department of Health’s central alerting system (https://www.cas.dh.gov.uk), and organisations are required to act on these within a …