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Signals | Emerging issues from national review of serious patient safety incidents

Key risks emerging from review of serious incidents reported by the NHS to its National Reporting and Learning System (NRLS) are shared in in the form of Signals.


The NRLS now holds over six million patient safety incidents, which are reported from across the NHS in England and Wales. We review each reported incident of patient death or severe harm - around 350 every week. 


From the reviews, around 10 alerts a year are produced. These require actions by NHS organisations to reduce risks to patients. However, there is much rich learning in addition to alerts and this is shared as Signals. The latest set of Signals was issued 28 February 2012.  


We would like to hear from you – please contact us with anonymised copies of local investigations or information about your initiatives to reduce risks in any of these areas.


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TitleIssue dateType
Recognising and instigating prompt treatment for necrotising fasciitis | Signal28 February 2012Signal
Prevention of Harm with Buccal Midazolam | Signal28 February 2012Signal
Risk of skin-prep related fire in operating theatres | Signal28 February 2012Signal
Risk of harm following gastric bypass | Signal28 February 2012Signal
Diagnosis of death after cessation of cardiopulmonary resuscitation | Signal28 February 2012Signal
Risk of harm from CPM syndrome following rapid correction of sodium | Signal28 February 2012Signal
Patient safety issues related to gastrostomy | Signal28 February 2012Signal
Risk of harm from ingestion of Vernagel | Signal29 September 2011Signal
Risk of harm from acupuncture treatment including pneumothorax | Signal29 September 2011Signal
Risk of harm from retained guidewires following central venous access | Signal29 September 2011Signal
Risk of air embolism when removing central lines | Signal29 September 2011Signal
Tracking subsequent removal of intentionally retained swabs | Signal29 September 2011Signal
Risk of bowel obstruction post orthopaedic surgery: “Ogilvie Syndrome” | Signal29 September 2011Signal
Rapid deterioration in patients with Systemic Lupus Erythematosus | Signal29 September 2011Signal
Prevention of harm with alfacalcidol preparations | Signal29 September 2011Signal
Use of plastic bags for self harm | Signal25 March 2011Signal
Intravenous morphine administration on neonatal units | Signal25 March 2011Signal
Monitoring patients with fractured ribs | Signal25 March 2011Signal
Imperforate anus in newborn babies | Signal25 March 2011Signal
Early detection and treatment of acute limb ischaemia | Signal25 March 2011Signal
Outbreak of prosthetic valve endocarditis | Signal25 March 2011Signal
Monitoring plasma sodium levels in babies | Signal25 March 2011Signal
Multiple use of single use injectable medicines | Signal25 March 2011Signal
The safe use of ultra low beds | Signal14 February 2011Signal
Risk of harm to patients who are nil by mouth | Signal14 February 2011Signal
Risk of harm from compression bandages | Signal14 February 2011Signal
Missed diagnosis of fractures in children | Signal14 February 2011Signal
Airway suction equipment | Signal14 February 2011Signal
The risk of harm when using intravenous connectors in children and babies |...14 February 2011Signal
The risk of harm from children and neonates entangled in lines | Signals14 February 2011Signal
Haemorrhages from arteriovenous fistula | Signal14 February 2011Signal
Patients’ resuscitation status in community hospitals | Signal14 February 2011Signal
Over sedation for emergency procedures in isolated locations | Signal14 February 2011Signal
Overdose of intravenous paracetamol in infants and children | Signal29 October 2010Signal
Anticoagulated patients and head injury | Signal29 October 2010Signal
Delay in diagnosis and treatment of spinal cord compression | Signal29 October 2010Signal
Haemorrhage following removal of femoral catheters | Signal29 October 2010Signal
Wrong site nerve block | Signal29 October 2010Signal
Non-invasive ventilation | Signal 29 October 2010Signal
Low temperature as a sign of sepsis in newborn babies | Signal29 October 2010Signal
Risk of harm to bariatric patients from delays in treatment | Signal29 October 2010Signal
Detecting harm following paracetamol overdose | Signal29 October 2010Signal
Accurate patient weight | Signal29 October 2010Signal
Neonatal resuscitation | Signal26 February 2010Signal
Contact injuries from wheelchairs in hospitals | Signal26 February 2010Signal
Transferring neurosurgery patient images | Signal26 February 2010Signal
Wrong strength phenol | Signal26 February 2010Signal
Mental health patients in transit | Signal26 February 2010Signal
Injectable medicines in theatres | Signal26 February 2010Signal
Extravasation of neonates revisited | Signal26 February 2010Signal