Recurring concern
Unreliable dissemination of safety-critical clinical guidance and learning
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Request correctionFirst reported 19 Sep 2013•Latest report 4 Nov 2025
What this concern includes
Includes failures to disseminate, cascade, communicate or make accessible safety-critical clinical guidance, policy or practice changes, revised training, best practice and lessons learned to the clinicians, teams or care units responsible for applying them, including the anchor's clinical-care policy and practice changes and comparable cross-unit or cross-clinician dissemination failures.
Not included
- Excludes failures in the substantive content, evidence base or updating of clinical guidance where dissemination is not the unsafe condition.
- Excludes failures to implement or embed a change after it was reliably disseminated, unless the report also identifies a dissemination failure.
- Excludes generic communication, record-keeping, training or organisational-learning deficiencies without a material safety-critical clinical guidance, policy-change, best-practice or learning dissemination context.
- Excludes dissemination processes bounded to a distinct named system, hazard or statutory pathway when that named concern provides the more specific supported boundary.
- Reports
- 14
- Individual concerns
- 14
- Date range
- 2013–2025
- Stated actions
- 16
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Shortcomings in dissemination of clinical-care policy and practice changes
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Implement structured dissemination of clinical policy changes through central coordination, digital alerts, manager briefings, safety huddles, meetings, rapid training and e-learning.
Stated by Blackpool Teaching Hospitals NHS Foundation Trust -
Action
Refine policy document control, approval, risk stratification, communication, intranet access, training linkage and compliance oversight through established committees and supporting teams.
Stated by Blackpool Teaching Hospitals NHS Foundation Trust -
Action
Roll out Alertive to issue critical messages, record staff acknowledgements, and subsequently scope its use for cascading policy documents.
Stated by Blackpool Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to ensure relevant NICE guidance reaches applicable organisations
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Reflect on the report and incorporate lessons into NICE’s approach to disseminating future guidance.
Stated by National Institute for Health and Care Excellence
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Local commissioners and providers are responsible for reviewing new NICE guidance and considering its relevance within their settings.
Stated by National Institute for Health and Care Excellence
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Concerns raised1
Failure to ensure all doctors receive learning-point discussions
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Develop shared server and intranet locations so staff can access incident-learning reports and written materials.
Stated by George Eliot Hospital NHS Trust
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Concerns raised1
Lack of national provision for sharing maternity induction-of-labour learning
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to effectively communicate key changes in clinical practice and advice
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to disseminate revised Clinical Risk Assessment training to treating clinicians
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Establish and operate a working group to devise a pilot of revised clinical risk training.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Concerns raised1
Failure to establish whether information about olanzapine-associated drug reaction with eosinophilia and systemic symptoms is known to clinicians nationally
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to communicate urgent and emergency guidance clarifications to doctors and relevant NHS staff
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Communicate the updated guidance and case learning to the wider organisation through the communications department.
Stated by St George'S University Hospitals NHS Foundation Trust -
Action
Highlight the policy changes at Information Governance Committee meetings and in all Information Governance training sessions.
Stated by St George'S University Hospitals NHS Foundation Trust
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Concerns raised1
Lack of circulation of call termination guidance to call handling staff
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Revise the call-termination guidance and circulate it to all EOC supervisors.
Stated by North West Ambulance Service NHS Trust -
Action
Brief all call takers individually on the revised guidance and obtain signed confirmation that they understand it.
Stated by North West Ambulance Service NHS Trust -
Action
Establish a reminder system to prompt periodic recirculation of call-termination guidance to call takers.
Stated by North West Ambulance Service NHS Trust
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Concerns raised1
Failure to share asthma-care learning continuously across medical professionals
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Operate the National Paediatric Asthma Collaborative to coordinate clinicians, commissioners and voluntary organisations in improving children’s asthma care.
Stated by NHS England -
Action
Share and implement learning from the review of paediatric asthma deaths across the country.
Stated by NHS England -
Action
Share Healthy London Partnership learning, standards, clearer messaging and E-asthma tools across NHS commissioners to support active asthma-management measures.
Stated by NHS England
Data last updated 7 September 2026