Patient safety updates - 13 December 2012
New policy, guidance and initiatives from across the UK relevant to patient safety. For more information about the patient safety theme see Quality and Safety e-Bulletin: patient safety.
Some of the resources linked to are in PDF format - see how to access PDF files.
Agency for healthcare Research and Quality (AHRQ) Patient Safety Network: Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit. This piece details a number of evidenced-based practices to help detect, prevent, and treat delirium, which is now seen as a patient safety hazard.
Agency for healthcare Research and Quality (AHRQ) Patient Safety Network: In Conversation With… Sharon K. Inouye. A leading expert in geriatrics research and innovation, Dr. Inouye developed and validated a widely used tool, the Confusion Assessment Method (CAM), to identify delirium.
Aware in care. This American website seeks to help hospitals and patients prevent medication errors in hospitalised patients with Parkinson disease.
BBC Health: Whooping cough jab uptake hailed by health officials. Uptake of the whooping cough vaccine in pregnant mothers has been "extraordinarily good" in England. The jab was introduced UK-wide in the autumn as an emergency measure to protect newborn babies during the worst outbreak of the disease in 20 years.
BMC Health Services Research: Detecting inpatient falls by using natural language processing of electronic medical records. “Incident reporting is the most common method for detecting adverse events in a hospital. However, under-reporting or non-reporting and delay in submission of reports are problems that prevent early detection of serious adverse events. The aim of this study was to determine whether it is possible to promptly detect serious injuries after inpatient falls by using a natural language processing method and to determine which data source is the most suitable for this purpose.”
BMC Health Services Research: Design of a prospective cohort study to assess ethnic inequalities in patient safety in hospital care using mixed methods. “While US studies show a higher risk of adverse events (AEs) for ethnic minorities in hospital care, in Europe ethnic inequalities in patient safety have never been analysed. Based on existing literature and exploratory research, our research group developed a conceptual model and empirical study to increase our understanding of the role ethnicity plays in patient safety. Our study is designed to (1) assess the risk of AEs for hospitalised patients of non-Western ethnic origin in comparison to ethnic Dutch patients; (2) analyse what patient-related determinants affect the risk of AEs; (3) explore the mechanisms of patient-provider interactions that may increase the risk of AEs; and (4) explore possible strategies to prevent inequalities in patient safety.”
Care Inspectorate: ‘Preventing Infection in Care’ An educational programme in infection prevention and control for people who work in care homes and the home environment. In September 2011 six care home and care at home services in Scotland volunteered to be part of an early implementer programme for the preventing Infection in Care educational resource. This report brings together their experiences, findings and lessons learned.
General Medical Council (GMC): GMC launches confidential helpline for doctors to raise concerns about patient safety. For the first time doctors who are worried about patient safety will be able to contact the General Medical Council (GMC) through a new confidential helpline. The helpline will enable doctors to seek advice on any issues they may be dealing with and to raise serious concerns about patient safety when they feel unable to do this at local level.
Harm Free Care. The NHS Institute for Innovation and Improvement has released new guidance on its Harm Free Care site for patients. The new resources provide information for patients on the steps they can take to help minimise the risk of developing one of the four most common avoidable harms: falls, pressure ulcers, blood clots and infection from urinary tract infections (UTI).
Being safe (PDF 645.6KB).
Health and Social Care Information Centre (HSCIC): Abuse of vulnerable adults: cases referred by English councils up 11 per cent in a year. English councils referred 108,000 cases of alleged abuse against vulnerable adults for investigation in 2011/12, an 11 per cent rise on the previous year, provisional figures show. As well as referrals data from all 152 councils in England, data submitted to the Health and Social Care Information Centre (HSCIC) also suggests alleged abuse is most commonly at the hands of carers or family.
Health Affairs: Results Of An Effort To Integrate Quality And Safety Into Medical And Nursing School Curricula And Foster Joint Learning. “Medical and nursing schools that participated in the Retooling for Quality and Safety initiative, funded by the Josiah Macy Jr. Foundation, made major progress toward integration of health care improvement and patient safety into their required curricula. IHI Open School authors provide insights into incorporating improvement and safety training into required curricula, identifying learning goals that require interprofessional education, and strategies for overcoming common challenges”. (American article).
Health Foundation: Using safety cases in industry and healthcare. This report presents the results of a study that reviewed the use of safety cases in six safety-critical industries, as well as the emerging use of safety cases in healthcare. Details of these reviews are available in the supplements to the report. The aims of the study were to describe safety case use in other industries, to make pragmatic recommendations for the adoption of safety cases in healthcare and to outline possible healthcare application scenarios.
Health Protection Agency (HPA): Seasonal norovirus activity. Figures show a drop in the number of hospital outbreaks of norovirus from 53 in the two weeks to November 25 2012, down to 40 in the two weeks to the 2 December 2012. The latest weekly report is now published. However, the total number of confirmed laboratory reports of norovirus (both from community and hospital cases) is 2,313 for the season which is 64 per cent higher than the same period in the last season when there were 1,412 cases reported. There are no clear indications as to why activity is higher this year.
RCN: Schoolchildren with health needs ‘at risk’. The Royal College of Nursing and Unison are calling for urgent action to protect children and young people with health needs in schools. A survey of school support staff and school nurses for the RCN and Unison shows that despite many examples of good practice, a growing number of children with increasingly complex health needs are being put at risk as staff are being pressurised into caring for them without enough training, supervision and support. This can include tube feeding, airway suctioning, tracheostomy care and catheterisation. Children with long-term conditions including asthma, diabetes, epilepsy or anaphylaxis also need support. Two-thirds of registered nurses who oversee health care provision in schools say that specialist care plans are not always in place. These nurses play a crucial role in developing individual care plans and providing an important link between school, home and the community.
RCN: Patient safety and human factors. The RCN has launched a new patient safety and human factors resource. This area of the RCN website looks at the way certain “human factors” including communications and teamwork play a crucial part in day to day delivery of healthcare. The negative effects of these can be reduced by evidence-based tools and interventions. The website identifies the tools and how they are being used to develop more safety conscious health services. The website complements the online learning 'Making sense of patient safety' that uses clinical scenarios to show the role nursing teams can play in protecting patients from harm.
Royal College of General Practitioners: Tuberculosis learning module for GPs. The Royal College of General Practitioners (RCGP) has produced a new online learning module for GPs to combat rising Tuberculosis rates in the UK. The number of TB cases in the UK has been increasing over the past 20 years, with over 70 per cent of cases occurring in residents born outside the UK. Early diagnosis is vital and GPs play a key role in preventing, identifying and treating patients with TB. The course, Tuberculosis in General Practice, was developed in partnership with TB Alert and the Health Protection Agency, and is available free of charge to health professionals via the RCGP Online Learning Environment.