Northwick Park Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment we rated this key question good, at this assessment the rating changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. They did not always detect and control potential risks in the care environment and make sure equipment, facilities and technology supported the delivery of safe care. The department did not always have enough staff with the right skills to safely care for patients.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and people were protected and kept safe. Leaders embedded a culture of openness and collaboration. Staff managed medicines well and involved people in planning any changes.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was a no blame culture meaning staff were confident that any incident reported would result in shared learning. Staff we spoke with knew what incidents to report, how to report them and were encouraged to do so by senior leaders, they gave us examples of when they had reported incidents and the actions that had been taken. The service used an electronic system all staff could access, and staff told us this was easy to do. The data we reviewed showed that the service was reporting a range of incidents including no harm incidents and those that had resulted in severe harm. On average the division reported around 700-800 incidents per month with around 93% of these incidents being categorised as low or no harm. We were not provided with specific data that showed how many incidents the ED and UTC reported. The service reviewed these incidents under the new incident framework in line with the NHS standards.

Staff spoke about incidents that had occurred in the department, they stated they received feedback and learning following an incident was shared with all staff. Learning was cascaded through team meetings, handovers, safety huddles and emails. Where an incident related to a specific member of staff, individual meetings would be arranged for personalised feedback and learning. There was evidence that changes had been made as a result of the outcome of investigations and staff were able to give a range of examples. For example, following a serious incident, changes were made to the department with the introduction of the sepsis room creating an additional space for patients to have intravenous antibiotics administered quickly.

Staff understood how important it was to be open and transparent with patients and their relatives and that this was an important part of the learning process. However not all staff knew this was called duty of candour. The trust had an up-to-date duty of candour policy that staff could access. We saw duty of candour screen savers on computers helping make staff aware of the policy.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Between July 2024 and June 2025 there were 119,618 attendances to the emergency department (ED) and 78,744 to the urgent treatment centre (UTC). The service accepted patients who were conveyed by ambulance, who walked in and were referred by their GP.

On arrival in the department all walk in patients joined a queue to be streamed by the ‘hello’ nurse. Patients were often queuing outside the door; we observed a wait time of around 15 minutes before people entered the department. The area was monitored by a security officer who would prioritise patients if they thought it was necessary, however they were not medically trained and this was inconsistent, we observed a young child being prioritised when they joined the queue and at other times children joining the back of the queue when they arrived and not prioritised. During busy times we did not see any additional clinical support at the front door to help streamline patients meaning critically unwell patients may not be prioritised and escalated therefore delaying treatment and impacting on patient care.

The hello nurse could refer very unwell patients straight to resuscitation and streamed all other patients between the ED and UTC. Patients were triaged at reception by a senior registered nurse. Children were not triaged by a paediatric nurse; however, this is not a requirement as per national guidance but is considered best practice. Senior leaders told us staff received additional training in triage for adults and children and were signed off as competent. Data showed that 100% of band 7 nurses had completed their training and had been signed off as competent. We noted 95% of band 6 nurses had completed their training with 88% signed off as competent. While 61% of band 5 nurses had completed their training only 13% had been signed off as competent. However, senior leaders told us triage is only undertaken by a band 6 or band 7 nurse who are signed off as competent, those who are not signed off were not allocated to this area. We saw an example of 2 paediatric patients with similar injuries being streamed differently resulting in different care being provided. Senior staff told us that refurbishment works to the entrance area of the department, which commenced the week of the inspection, would resolve this issue as all paediatric patients would be sent directly to the paediatric ED and triaged by paediatric staff away from the main reception area. This would mean a consistent approach to triaging paediatric patients.

NHS England set the standard that all patients should be assessed promptly within 15 minutes of arrival in the department and within 1 hour by a clinician. The service assessed 91.3% of patients within 15 minutes and 91.2% of patients were assessed by a clinician within 1 hour whether they arrived by ambulance or were a walk-in patient.

Adult patients had a falls assessment completed and if necessary, they were provided with yellow socks to help identify them to staff caring for them. This meant mitigating actions could be taken to reduce the risk of these patients falling. Falls in the department were monitored at the quality and risk committee. There had been 6 falls reported in ED during July 2025 but none in SDEC or UTC.

The trust used a nationally recognised triage system to ensure patients received a consistent and structured assessment. The system used icons to flag individual patient needs or risks. This system did not require a mental health assessment for all patients attending however, staff could add notes to the comments section if a patient presented with a mental health concern. The system did not prompt staff to ask patients undergoing chemotherapy whether they were at a higher risk of infection however staff told us they always asked but there was a risk this might go unrecorded. The department had neutropenic sepsis pathway in place and staff told us they had a chemotherapy policy for the waiting room to follow.

Patients waiting in ED were seen in the rapid assessment unit (RAU) where investigations were ordered and patients placed on pathways, for example escalated to resuscitation for higher level care. Patients were seen by a senior clinician to initiate early treatment. In the patient notes we reviewed, we found appropriate referrals for imaging and specialist services, such as orthopaedics. Patients arriving by ambulance had a separate entrance to the department and were assessed in an area known as the pitstop. Patients were assessed by a doctor and nurse and triaged appropriately. The aim of this area was to take over from the ambulance crews in a timely manner and release the crews with minimal delays.

When patients were referred to ED same day emergency care (SDEC), managed by the ED department, which may be the most appropriate place for these patients to receive care, the time they were in the department continued to be recorded on the electronic patient record but they were no longer reportable on the 4-hour target in line with national SDEC pathways.

Not all patients were transferred to the ward under a speciality team in a timely manner. On the day of the inspection one patient had waited more than 19 hours to be transferred and admitted to a ward which breached the 12-hour national standard set by NHS England, which sets trusts the target that no more than 2% of patients should wait 12 hours or more from the time of arrival at an ED before being admitted, discharged, or transferred. In the last 6 months 14.4% of patients breached the 12-hour national standard. The flow programme board was established in May 2025 to track the departments flow. At the time of the inspection there were a number of open actions on the action log, for example exploring the possibility of extending the opening hours of the same day emergency care (SDEC) ward. We attended a site meeting where breaches were discussed with the other services in the hospital and plans were made to admit patients to the appropriate services.

The trust had a full capacity protocol (FCP), to assist in the management of overcrowding in the ED. Senior leaders acknowledged that the department had to adapt and operate differently in these situations to manage the risk and ensure patient safety. The FCP included the criteria for activating the protocol, actions to be taken including the escalation processes. This facilitated patients receiving timely and appropriate treatment and improve patient flow by using all available resources effectively. The trust reported the FCP during the submission of Operational Pressures Escalation Levels (OPEL) score 4 times a day.

The medical and nursing handovers we attended, were informative and responsive to the department’s needs. The medical handover immediately allocated medical staff to start bringing down the wait times in the department, to ensure patients received timely treatment.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff had training on how to recognise and report abuse, and they knew how to apply it. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff were able to describe how they would submit a safeguarding alert using the electronic system and gave examples for what to look for including recognition of exploitation. In the 12-month period July 2024 to June 2025 the department made 622 adult safeguarding referrals and 2061 children’s referrals showing staff knew how to recognise and report abuse.

Staff received training in adults’ and children’s safeguarding as part of their mandatory training, the level of training was dependent upon their role. At the time of the inspection, data showed that over 97% of medical staff had completed their safeguarding training, which was above the trust target of 90%. However, not all other staff groups had met the 90% target. Nursing staff had not met the target for safeguarding adults’ level 3, 80.95% had completed this training and for children’s level 3 training, 87.4% were compliant. The divisional director of nursing chaired a monthly mandatory training meeting with the area leads to review training compliance and explore what was being done to improve compliance rates. It was acknowledged that some gaps in compliance were down to staff on long term sick leave and availability of training. The department presented a breakdown of their compliance and highlighted where additional capacity for different training was required. We were not provided with evidence to demonstrate that plans were in place to address the shortfall in the provision of some training. An internal mandatory training tracker was used by senior staff to record communication with non-compliant staff and included dates for future training. This meeting validated and challenged the data entry to ensure the online platform was being updated correctly having previously identified an error with the learning platform.

The electronic system flagged if a patient had a child protection plan in place, or if a person frequently accessed services throughout the area. The trust had named safeguarding leads across the hospital who staff could access for advice regarding safeguarding matters and staff we spoke with knew how to access them.

The trust had a safeguarding policy in place that was in date and referenced national guidance. Staff knew how to access this.

Staff received training on learning disability and autism. Compliance across all staff groups met the trust 90% target, with several staff groups 100% compliant.

Mental Capacity Act training formed part of the safeguarding modules. Capacity was documented in patients notes and risk assessments were carried out to ensure patient safety. The service employed two registered mental health nurses providing support to staff in the department. Their rota provided cover for the day shifts, 7 days a week and all but 2 days a month were covered. There was no mental health nurse on duty on the night shifts. When the mental health nurses were not on shift the nurse in charge would provide support for staff.

The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service introduced the managing vulnerable patients in the cohort queue policy. This set out who was considered a vulnerable patient and who to prioritise but did not include what actions staff should take. We observed a vulnerable patient at the back of the cohort queue waiting to be assessed and had not been prioritised. It was unclear what actions should have been taken and how compliance with this policy was monitored.

The service had a standard operating procedure (SOP) for patients cared for in temporary escalation (TES) areas. Leaders told us while they did not want to normalise corridor care, an SOP had been implemented so there was a clear direction for staff to maintain patients’ safety. However, the policy was not always adhered to. Most patients were located in a corridor directly alongside the rapid assessment unit where staff were located. Later in the day when the department was at its busiest, patients were placed in a corridor behind a closed door. There were no staff members caring for patients in this area, placing patients at risk of harm if they deteriorated as this would not be identified in a timely manner. This was not in line with the policy that stated all patients must be in the line of sight of the nursing team. Staff told us these patients had not yet been handed over to them by the ambulance service. The trust had a standard operating procedure with the ambulance service where the department could request support from paramedic crews to assist cohorting patients before they were handed over to nursing staff, allowing other ambulance crews to be released. However, at the time of our inspection there were no paramedics present in this area. As these patients were in the department it was the trust’s responsibility to care for these patients but not all staff we spoke with understood this.

Patients in TES areas did not have access to a call bell or other method of seeking assistance. On review of the trust’s patient safety data, we could not find any incidents reported relating to patient harm as a result of patients not having access to a call bell in the TES areas. However, this did place patients at risk of potential harm. Following the inspection leaders told us the area had been risk assessed with environmental factors taken into consideration. The service used national guidance to assess the area and produce the standard operating procedure for the department.

It had been highlighted at a quality and risk meeting that the issues around the TES areas and that some metrics such as ambulance conveyances, blue light conveyances and cohort numbers were not collected. It was unclear from the minutes if the department had plans to collect this data and when this would commence. Leaders told us issues in TES were reported at the Integrated Performance and Quality Report (IPQR). We reviewed the slides and saw metrics were discussed however this was not the metrics discussed in the quality and risk meeting minutes.

Patients could request a chaperone to accompany them, however there was no information displayed regarding this; therefore patients may not realise this was an option. Leaders told us staff would discuss this with patients individually. However, we did not observe this during the inspection as we were not present during the clinical assessment with patients.

Staff used a nationally recognised tool to identify deteriorating patients. Observations of vital signs were recorded by staff, and the national early warning score (NEWS) and paediatric early warning score (PEWS) was calculated and recorded. The service had a clear escalation policy for deteriorating patients and staff we spoke with understood the importance of escalating patients quickly.

Staff understood how to deal with specific risk issues such as sepsis. The emergency department had a dedicated sepsis treatment room with all necessary documentation and equipment, including medicines for the rapid assessment and treatment of sepsis. There was national guidance for how quickly patients should receive treatment for sepsis based on their presentation, known as the Sepsis 6. This included giving antibiotics to a patient with suspected sepsis within 1 hour of arrival in the ED. The data we reviewed showed a significant improvement in patients receiving antibiotics within 1 hour of arrival in the ED. In July 2024, before the introduction of the sepsis room, 30% of patients received antibiotics within 1 hour. In June 2025 this had risen to 95%, demonstrating the positive impact the sepsis treatment room had had on patient safety.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The department had several areas for patients to be cared for and treated in depending on their acuity. Patients were assessed and moved accordingly.

The waiting area was small and accommodated patients waiting for the emergency department (ED) and urgent treatment centre (UTC). The department was due to undergo building work to redesign the layout of the entrance and waiting areas immediately following the inspection. During busy times there was not enough seating, and we observed people sitting on the floor or standing. When the department started to get busy, the security staff restricted the number of people accompanying the patient to only one person to reduce the numbers in this area. There were 3 security staff in the waiting area who assisted staff in observing the area. The area was very loud and at times it was not possible to hear names being called by staff or announcements on the public address system. Due to the layout of the waiting area and the number of people waiting, it was not possible for triage staff to observe all the patients for any signs of deterioration. However, to mitigate the risk of deteriorating patients being missed there were 6 rounds a day where patients were assessed and staff walked through the waiting area continuously. However, while most patients were seen and assessed by a clinician within 60 minutes, some patients did wait longer than 4 hours in the waiting room and therefore could deteriorate in between the regular rounds and their deterioration may not be identified in a timely manner.

Some patients arrived at the department when an appointment with a primary care service was more suitable. The UTC engaged with patients and helped them register with a GP and access appointments at a local medical centre. This encouraged people to use the different health settings more appropriately.

The waiting area for paediatric patients could only be accessed using a swipe card meaning access was limited to paediatric patients and their relatives. The paediatric waiting area was small and used for patients waiting for the ED and UTC. Staff in this area were located behind a locked door and the window which looked out over the waiting area was covered in posters, meaning staff might not be able to observe all patients in the area. We were told about a paediatric patient who deteriorated whilst waiting, this was not identified in a timely manner as staff did not have full oversight of the area. Despite this incident, at the time of the inspection the window was still covered in posters meaning the waiting area was not clearly visible.

Patients arriving by ambulance entered the department by a different entrance where ambulance crews could check patients in with a nurse in an area known as the pitstop. The crews provided a verbal handover and staff in the pitstop were able to prioritise patients requiring urgent attention. At busy times we observed patients waiting in the foyer of the department to be admitted into the department and to have their initial assessment as there were no pitstop cubicles to transfer these patients to. The ambulance crews we spoke with told us this was not unusual, and they often had to wait in the foyer to handover or keep the patient in the back of the ambulance while waiting to handover. This not only delayed the ambulance crews and impacted on their ability to respond to other calls, it placed the patient at risk of not receiving timely care and treatment. Leaders told us fire safety regulations limited the number of patients they could accept into the department. Once this threshold had been reached the department could not accept any more patients and surge calls were held with the ambulance provider to discuss the possibility of diverting patients to other emergency departments.

Patients were regularly waiting in temporary escalation (TES) areas. The department used 2 corridors to cohort patients waiting. Privacy screens were not used in TES to protect patient privacy when being examined and conversations could be overheard. Patients in this area did not have access to a call bell. Patients waiting in TES and HDU did not have access to a toilet and would have to leave the area to find one. It was not clear for patients where the nearest facilities were.

The department had several resuscitation trolleys, for example the rapid assessment unit had a resuscitation trolley located in a trauma bay for patients acutely unwell waiting to be transferred to another area. The trust had risk assessed the department and resuscitation trolleys were within 30 to 40 seconds of all areas, including the temporary escalation area. We reviewed the logs of 3 resuscitation trolleys and found they were checked daily by staff and signed off as being appropriately stocked.

The environment was well laid out, was visibly clean and tidy and most of the areas we visited had enough space and appropriate equipment. We observed that areas were uncluttered and had appropriate storage, equipment was stored properly and well maintained. Staff knew how to report faulty equipment and told us when they did it was resolved quickly.

Rooms and bays had curtains and doors to maintain privacy. The service had a ligature light room which met the national guidance for areas that patients at risk of harming themselves should be cared for in. It had an observation window, two-way doors, and access to a toilet. There were also 2 other rooms which could be converted from being set up for acutely unwell patients to a room suitable for a patient with a mental health condition.

We observed that all handovers were undertaken in a designated area where patient confidentiality could be maintained.

The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff in all areas of the department. They did not always make sure staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Managers had calculated the number and grade of nursing staff required using a nationally recognised staffing tool and reviewed staffing levels twice a year. This provided evidence-based decision making on workforce requirements. There were 5 levels of care with associated descriptors to determine the level of care a patient needed. This allowed staff to measure how unwell a patient was and how reliant they were on nursing care to have their needs met. The tool generated a recommended establishment of staff required to safely manage the department. The department worked to a ratio of 1 nurse to 4 patients and 1 nurse to 2 patients in resuscitation.

The TES area was not part of the substantive staffing model but was counted in the daily numbers of staffing. Additional bank shifts were added to the rota to have additional support for the TES area. We observed only 2 registered nurses looking after 22 patients in the temporary escalation (TES) areas. The department had a TES procedure which stated a ratio of 1 nurse to 5 patients, this was in line with NHS safer staff recommendations. This meant the TES areas were not safely staffed in line with the trust’s policy and place patients at risk of harm.

At the time of our inspection, nursing vacancies were 0.8% and leaders were proud they were almost at their full establishment of 31 nurses. The fill rate of shifts was between 96% and 99% for nurses and 85% to 96% for healthcare assistants between January 2025 and June 2025. Gaps were filled with bank staff and the service did not use agency staff. The fill rates for medical staff was 99.7% which included 26 consultants. Medical staff had a staggered shift start and included 8 senior decision makers per day. The Royal College of Emergency (RCEM) medicine suggests 1 consultant per 4000 annual attendances. Based on the number of patients attending ED over the last 12 months, using this ratio it suggests the department should have 29 consultants. However, this is guidance, and the complexity of the patients and department size needs to be considered. The department was not a major trauma centre; therefore, the ratio of consultants had taken this into account when identifying the medical staffing establishment.

The clinical lead recently undertook a data analysis of patient attendances against staffing and factors that impacted performance. They found that rather than the total number of ambulances, it was the arrivals by blue light that impacted performance. As a result, the rota was reviewed and opportunities identified to redeploy staff from another of the trust’s sites which led to improved performance. This analysis supported a business case to increase the number of advance care practitioners and was supported by executives. At the time of our inspection funding had not been agreed for the additional posts.

Most staff we spoke with said they thought the department had enough staff to safely care for patients. Staffing numbers were discussed at the morning site huddle and staff moved across the division accordingly, in line with the safe staffing and escalation policy. However, at times staffing numbers did impact on patient care, for example we observed a patient’s medication being delayed as a result of there not being a second member of staff to assist administering medication. An area of concern raised with us was healthcare assistants being moved to provide one to one support leaving gaps in the area they had been working in.

All staff received mandatory training. Data showed that across all staff groups, compliance stood at over 80%, with 97.71% of medical staff and 93.75% of nursing staff having completed their mandatory training.

Staff received additional training depending on their role. We reviewed the compliance rate for the additional training that some staff were required to complete. We noted that 81% of band 5 nurses, 93%, band 6 nurses and 89% of band 7 nurses had completed their paediatric immediate life support (PILS) training and 90% of band 5 nurses, 93% of band 6 nurses and 94% of band 7 nurses had completed their immediate life support (ILS) training. Medical staff received additional levels of life support training. The compliance rates for medical staff based at Northwick Park Hospital and those who worked across sites, were in excess of 75% for advance life support, advance trauma life support, and European paediatric advance life support.

The service was supported by a team of security officers. They were employed by an external agency and received appropriate training including safeguarding and conflict resolution. All staff we spoke with told us security officers were an invaluable part of the team and spoke highly of them. Staff told us they were able to defuse situations and support staff to provide one to one care for patients if required.

The service generally assessed and managed the risk of infection. They did not always detect and control the risk of it spreading or shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. We observed the use of ‘I am clean’ stickers indicating equipment had been cleaned and was ready for use. Staff told us they knew how to report broken equipment, and it was usually resolved quickly.

All ward areas in the emergency department and urgent care centre were visibly clean, and furnishings were well-maintained. We saw cleaning staff in the department throughout the day helping maintain a clean environment.

The matrons worked with cleaning contractors to audit different areas of the department for cleanliness. The auditing tool they used produced a failure analysis report so they could review where improvement was needed. We reviewed the analysis report, which recorded 81 instances of dust on surfaces over the past 12 months. Actions were taken as a result, and we saw these were followed up at the governance meeting. For example, matrons carried out daily walkabouts of the area alongside housekeepers and nursing staff to ensure improvements were maintained and any issues were identified and resolved promptly. The department had Infection Prevention and Control Assurance audit Improvement plans, staff were assigned actions and reported to the ED matron. The actions in the plan were on track for completion by the agreed dates. Learning was shared at staff huddles and infection prevention control nurses carried out daily walk abouts to review the environment and engage with staff.

Most staff adhered to infection control principles, including handwashing and being bare below the elbow. We observed staff cleaning their hands and using hand gel, which was available throughout the department. However, we observed some staff moving between patients taking observations without washing their hands which was a potential infection risk.

Most areas we observed had access to hand washing facilities including the TES areas so staff could easily wash their hands. However, where patients received and initial streaming by the ‘hello’ nurse, there were no hand washing facilities available. This area was due to change within the next 6 weeks as refurbishment works had started the week of our inspection and staff would have access to hand washing facilities.

Infection Prevention and Control data was shared at the divisional quality and risk meeting. For example, in April 2025 the hand washing audit reported 90.7% of staff were compliant with hand washing. And MRSA screening compliance was 84.7%. We were not provided with action plans to demonstrate how the department planned to improve these compliance rates.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involve people in planning, including when changes happen.

Staff followed good practice in medicines management and did so in line with national guidance. Patients were given information about their medicines and received medicines as prescribed. Allergies were recorded in patient records, and they were given coloured wrist bands to wear indicating to staff that they had an allergy.

Medicine management was discussed at the Emergency Medicine Clinical Governance and Resuscitation Meeting. At the meeting it was highlighted that there was a national shortage of certain medicines and that different medicines were available. This ensured medicines that were not in stock were not prescribed.

The service used an electronic prescribing system. Medicines were stored securely in automated dispensing cabinets which were integrated with the electronic prescribing system and patients notes. Emergency medicines could be accessed in the event of an emergency meaning patients received medication in a timely manner. The pharmacy team had worked with the service to agree on how to store and access medication in the sepsis room in a way that kept medication safe and provided clinical staff with easy access in the event of an emergency.

The department had prepared ‘to take away (TTA) packs of medication which could be given to the patients to avoid delays in discharge. However, audits showed these had been underutilised. A review of the stock and usage was underway at the time of our inspection and depending on the results action would be taken to improve this service.

Medicines, including controlled drugs, were disposed of safely when no longer required and suitable records kept. Records of Controlled Drugs handling were accurate and made in line with legislation, best practice and local policies.

Quarterly medicines management audits were carried out, these included controlled drugs and room and fridge temperatures. Audits demonstrated that medicines were managed safely, such as medicines reconciliation, missed and delayed doses and relevant patient safety alerts.