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Patient safety prompts change in procedure

17 December 2020

Trusts are being recommended to adopt new practices to protect the safety of patients who need tubes inserted in their airways, thanks to a risk analysis project run by NHS Supply Chain.

It is part of the important clinical work undertaken by NHS Supply Chain to ensure the safety of products to protect patients.

In September a National Patient Safety Alert was issued after it was found that silver discs which are used on lubricant tubes to keep them sterile could be a potential hazard if they entered the tube leading to a patient’s airway. The silver colour made them hard to spot.

The alert prompted a patient safety review by registered nurse Theresa Bowles from NHS Supply Chain: Rehabilitation, Disabled Services, Women’s Health and Associated Consumables, provided by Collaborative Procurement Partnership.

Surgical procedure with laryngoscope

Her review also found the use of lubricant from tubes:

  • increased the risk of contamination and cross infection if the tubes were used for more than one patient
  • created more waste as only a small amount of the lubricant was needed for each procedure

NHS trusts will now be encouraged to buy 5g lubricant sachets instead, which have coloured packaging. They are available via the NHS Supply Chain catalogue.

Theresa Bowles, Clinical Engagement and Implementation Manager for NHS Supply Chain, said: “This project is an example of how we as clinicians can work with our procurement colleagues to improve patient safety and achieve that without any additional cost to trusts.

“By making a relatively minor change to the way they operate NHS trusts can reduce the risk of small parts from lubricant tubes entering a patient’s airway.

“The sachets are coloured so they stand out more if any bits come off them and if more lubricant is needed then another sachet can be used. This has the bonus of reducing waste, with the environmental benefits that brings.”

NHS Supply Chain will be communicating the recommended new practice through various customer communications, including through their NHS Supply Chain Customer Relationship Managers.

The review has been done with the support of Clinical and Product Assurance (CaPA) and NHS England/Improvement.

Jo Gander, NHS Supply Chain’s Director of Clinical and Product Assurance (CaPA) said: “This project demonstrates how crucial NHS Supply Chain’s clinical work is to protect the safety of patients. I’d like to thank Theresa and the tower team for identifying the problem and making improvements.”

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About NHS Supply Chain’s role in the Covid-19 response

  • The Government has set up new PPE Dedicated Supply Channel which is a parallel supply chain to the normal NHS Supply Chain service. It has been set up by Government to meet the urgent volume requirements for core personal protective equipment (PPE) items, allowing NHS Supply Chain to focus on ensuring the supply of medical devices and clinical consumables to our NHS.
  • The Government has set up a dedicated unit to focus on securing supplies of PPE led by the government’s commercial function. This unit is identifying PPE suppliers from across the globe to meet the increasing demand for a growing list of PPE products.  NHS Supply Chain’s PPE buying teams have been seconded to the unit which is led by the government.
  • NHS Supply Chain has expanded its operations to support the stand up of seven NHS Nightingale Hospitals set up across the UK, including NHS Nightingale London, Birmingham, North West (Manchester), Yorkshire and the Humber (Harrogate), Bristol, North East (Washington) and Exeter. Equipment and consumables supplied include ventilators, patient monitors and CT scanners.

About NHS Supply Chain

NHS Supply Chain manages the sourcing, delivery and supply of healthcare products, services and food for NHS trusts and healthcare organisations across England and Wales.

Managing more than 4.5 million orders per year, across 94,000 order points and 15,000 locations, NHS Supply Chain systems consolidate orders from over 800 suppliers, saving trusts time and money and removing duplication of overlapping contracts. 

Lord Carter’s report into efficiency and productivity in the NHS, published in 2015, identified unwarranted variation in procurement across the NHS, resulting in the need to improve operational efficiencies to transform a fragmented procurement landscape. To undertake this transformation the Department of Health and Social Care established the Procurement Transformation Programme (PTP) to deliver a new NHS Supply Chain.

The new NHS Supply Chain was designed to help the NHS deliver clinically assured, quality products at the best value, through a range of specialist buying functions. Its aim is to leverage the buying power of the NHS to negotiate the best deals from suppliers and deliver savings of £2.4 billion back into NHS frontline services by the end of the financial year 2022/23.

The new model consists of eleven specialist buying functions, known as Category Towers, delivering clinical consumables, capital medical equipment and non-medical products such as food and office solutions. Two enabling services for logistics and supporting technology and transactional services which underpin the model.

Key benefits the NHS Supply Chain will bring NHS trusts and suppliers include:

NHS trusts

  • Savings channelled back to frontline services
  • Releasing more time for core clinical activities
  • Greater NHS clinical involvement in purchasing decision
  • More effective introduction of new products.


  • Lowering sales and marketing costs
  • Single route into the national market
  • A joined-up approach across the NHS
  • Clear route for innovative products.

On 1 April 2018, a new commercially astute management function of the new NHS Supply Chain called Supply Chain Coordination Limited (SCCL) went ‘live’. The management function is responsible in driving strong commercial capability, providing a relentless approach to creating value, gain competitive advantage, become the strategic procurement partner of choice for the NHS, manage the delivery and performance of the Category Tower Service Providers and its enabling logistics and technology services whilst overseeing continuous improvement. SCCL is a limited company, wholly owned by the Secretary of State for Health and Social Care, SCCL is part of the NHS family. For more information on our category service tower providers go to

About CaPA

The Clinical and Product Assurance (CaPA) team of NHS Supply Chain is key to ensuring that all the products we supply are safe and reflect the needs and preferences of all our NHS partners.

This includes working with our NHS partners such as NHS England, NHS Improvement and the National Institute for Health and Care Excellence (NICE) to support the introduction of new technology and innovation into the supply chain that provides demonstrable benefits for our patients and users.

The CaPA team is responsible for three key areas of expertise:

•             Assurance framework

•             Patient safety

•             Innovation