What you need to know:

All practices must have a system in place to review, share, and act upon patient safety alerts
MHRA and other organisations send practices patient safety alerts regarding medications and devices which could cause harm to patients.  It is important that practices have a system in place to review these alerts and ensure that relevant team members have sight of these alerts and an action plan is devised to ensure patients are protected from harm.

CQC will check during inspections that practices have system in place to act upon patient safety alerts. CQC Mythbuster 91 explains what CQC will be looking for when they inspect practices.

Practices should identify which alerts relate to general practice and ensure that these are shared with relevant clinical teams.  This could be done during a monthly clinical meeting.  It is also important that clinicians who are not in attendance also have sight of these alerts.  This should be evidenced through attendance logs and a log of who has seen the alert.

Once the alert has been circulated, the practice should identify what actions need to be taken to prevent patient harm, such as identifying patients on relevant drugs, and how these patients will be recalled or monitored.

Important recent examples:
SGLT2 inhibitors and risk of Fournier’s gangrene” and “Mirabegron: risk of severe hypertension and associated risk of cerebrovascular and cardiac events”.

Practices may choose to share the SGLT2 alert with only their diabetic team, though all prescribers may need to be involved.  A suitable action plan could be to identify all patients on SGLT2 inhibitors so that they can be given an information leaflet about the risk of Fournier’s gangrene.

Practices may choose to identify all patients on Mirabegron and ensure they are regularly recalled for blood pressure checks or encouraged to provide home BP readings.

Patient safety alerts can be used as the basis for GP Trainee or undergraduate Quality Improvement Projects.