Patient safety updates - 13 September 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): CUSP toolkit. The CUSP (Comprehensive Unit-based Safety Program) toolkit includes training tools to make care safer by improving the foundation of how physicians, nurses, and other clinical team members work together. "It builds the capacity to address safety issues by combining clinical best practices and the science of safety. Created for clinicians by clinicians, the CUSP toolkit is modular and modifiable to meet individual unit needs"(American).

AHRQ: AHRQ Patient Safety project reduces bloodstream infections by 40 per cent. This unique American project reduced the rate of central line-associated bloodstream infections (CLABSIs) in intensive care units by 40 percent, according to the agency's preliminary findings of the largest national effort to combat CLABSIs to date. The project used the Comprehensive Unit-based Safety Program (CUSP) to achieve its landmark results that include preventing more than 2,000 CLABSIs, saving more than 500 lives and avoiding more than $34 million in health care costs.

BMC Nursing: Adjusting team involvement: a grounded theory study of challenges in utilizing a surgical safety checklist as experienced by nurses in the operating room. “Even though the use of perioperative checklists have resulted in significant reduction in postoperative mortality and morbidity, as well as improvements of important information communication, the utilization of checklists seems to vary, and perceived barriers are likely to influence compliance. In this grounded theory study we aimed to explore the challenges and strategies of performing the WHO's Safe Surgical Checklist as experienced by the nurses appointed as checklist coordinators.”  

Department of Health, Social Services and Public Safety (DHSSPS): Flu vaccination programme extended to all children. Health Minister Edwin Poots has extended the flu vaccination programme to all children in Northern Ireland from the autumn of 2014.

General Medical Council: New GMC child protection guidance comes into effect. New guidance from the GMC to help doctors protect children from abuse and neglect came into effect on 3 September 2012. The guidance covers children and young people who are living with their families or living away from home, including those being looked after by a local authority.

Health Protection Agency (HPA): Whooping cough cases continue to increase. The HPA states that 1,047 cases of whooping cough in England and Wales were reported to the HPA in July 2012, bringing the total number of cases so far this year to 3,523. Whooping cough, also known as pertussis, affects all ages. This ongoing outbreak is mainly in teenagers and young adults; however, there are high numbers of cases in very young babies. 235 cases have been reported in infants under three months so far this year, compared to 112 cases in 2008. There have also been six pertussis-related deaths in infants up to the end of July compared to five in 2008.
BBC Health: Newborn babies could get whooping cough vaccination. 

HPA: Gonorrhoea treatment resistance risk falls but new diagnoses rise. Latest Health Protection Agency (HPA) surveillance figures - released at the Health Protection 2012 conference - indicate that, for the first time in five years, the risk of resistance developing in currently recommended gonorrhoea treatments fell slightly in 2011.

HPA: Hantavirus Pulmonary Syndrome in the US. The Health Protection Agency has announced that it is aware of six confirmed cases, two of whom have died, of Hantavirus Pulmonary Syndrome (HPS) in visitors who had visited Yosemite National Park in California. Local HPA Health Protection Units are currently contacting UK travellers who may have stayed at the park. They are providing health advice and information on Hantavirus Pulmonary Syndrome and about the ongoing situation in the US. Approximately 100 UK travellers have been identified as having stayed at Yosemite National Park from mid-June to the end of August.

HPA: HPA survey reveals attitudes affecting flu vaccine uptake amongst London midwives. Uptake of the seasonal influenza vaccine amongst midwives in London could be improved according to a study presented at the Health Protection Agency's annual conference - Health Protection 2012 - at the University of Warwick.

HPA: Health effects of climate change in the UK 2012. In 2009 the latest long-range climate projections for the UK were published in order to inform the UK’s first Climate Change Risk Assessment (CCRA), required by the Climate Change Act (2008), covering 11 sectors across society. This HPA report complements the Health Sector report of the CCRA by providing scientific evidence of the wider risks to public health from climate change in the UK.
Press release.

HPA: Radon help at hand for Cornish residents. A radon testing programme in Cornwall has found more than 160 homes with levels of the radioactive gas at least five times the point at which the HPA recommends action to protect health. 

HPA: Second case of Anthrax confirmed in England. The Health Protection Agency (HPA) is aware that a person who injected heroin has died from anthrax infection in Blackpool Victoria Hospital. This death has occurred three weeks after another person who injected drugs also died in Blackpool from confirmed anthrax infection.

Implementation Science: Learning curves, taking instructions, and patient safety: using a theoretical domains framework in an interview study to investigate prescribing errors among trainee doctors. "Prescribing errors are a major source of morbidity and mortality and represent a significant patient safety concern. Evidence suggests that trainee doctors are responsible for most prescribing errors. Understanding the factors that influence prescribing behaviour may lead to effective interventions to reduce errors". The study applies a broad theory-based approach using the Theoretical Domains Framework (TDF) to investigate prescribing among a sample of trainee doctors.

Patient Safety First: Safer Surgery Week 2012: 24-30 September. Patient Safety First and the Clinical Board for Surgical Safety are hosting Safer Surgery Week, beginning on 24th of September. All Trusts in England are using the Surgical Safety Checklist in order to provide safer surgical care and Safer Surgery Week will be promoting a number of simple local activities designed for people and teams to quickly get involved in, + a series of online webinars with the aim of improving the quality and reliability of local implementation of the Five Steps to Safer Surgery. Webinars are scheduled for each day of the week and you can also sign up for email updates about the week.
RCN: Promoting safer surgery. Royal College of Nursing members are being encouraged to get involved with Safer Surgery Week.

RCN: Patient safety and human factors conference November 2012. Stimulating improvements in safety through a focus on nursing education and simulation training. There is a growing movement in modern healthcare to ensure that human factors are embedded within practice, policy, education, research and development and this conference will provide participants with information about the ways in which innovators are using human factors to continuously improve the safety and quality of patient care at the frontline. To be held on 23 November 2012 at Hallam Conference Centre London.