Patient safety updates - 21 February 2013

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.

DH: Infection prevention and control in care homes: information resource published. An information resource and summary document aim to assist care workers in care homes in taking all reasonable steps to protect residents and staff from acquiring infections, and provide information and guidance that will assist managers undertaking risk assessments and in developing policies.

DH: Importance of finger prick tests in managing type 1 diabetes highlighted. Healthcare professionals are being reminded of the importance of finger prick glucose testing for people living with type 1 diabetes.

DH: Ensuring an open NHS culture. The Secretary of State for Health has written to chairs of all NHS trusts to remind them of the importance of ensuring an open culture within the NHS. His letter is on the back of Robert Francis’s report into failings at Mid Staffordshire NHS Foundation Trust, and recent media coverage about staff being able to raise concerns about patient safety.   

DH: Horsemeat in UK food chain: reminder to NHS commissioned care providers. Providers of NHS commissioned care are being reminded of their responsibility to ensure they have rigorous processes in place with suppliers.   
Statement from Chief Medical Officer.

DH: Department recommends product label messages on vitamin D supplements for at risk groups. The statements have been agreed by the food supplements industry. "A significant proportion of the UK population have low vitamin D status, which increases their risk of vitamin D deficiency. This is a particular concern for pregnant and breastfeeding women, infants, the elderly and people who have low or no exposure to the sun".

Guardian: Elderly in care 20 times more likely to be on antipsychotics. "Sharp rise in medication, including chemical calming 'cosh', revealed in database study by Queen's University Belfast".

General Medical Council (GMC): GMC warns over doctors’ working hours. Some doctors in training are tired and stressed because of their working patterns which could be putting patients at risk, according to the General Medical Council (GMC).

Health Protection Agency (HPA): Measles at highest level for 18 years. There were 2,016 confirmed cases of measles in England and Wales reported to the Health Protection Agency in 2012, the highest annual total since 1994. The measles cases identified during 2012 have been associated with prolonged outbreaks in Merseyside and Sussex, as well as several smaller outbreaks in travelling communities across England and Wales.

HPA: Third case of novel coronavirus infection identified in family cluster. The Health Protection Agency has confirmed a third case of novel coronavirus infection in a family cluster, following the confirmed diagnosis of two cases announced earlier this week. The patient, who is a UK resident and does not have any recent travel history, is recovering from a mild respiratory illness and is currently well. This latest case brings the total number of confirmed cases globally to 12, of which four have been diagnosed in the UK. 

HPA: Blood-bourne virus testing annual review. Targeting testing: Health Protection Services Sentinel Surveillance of Blood-Bourne Virus testing (SBV) in England, Annual review 2011. This is the 10th annual review from the Immunisation, Hepatitis and Blood Safety Department's Sentinel Surveillance of Blood-Borne Virus testing (SBV). This review presents data on hepatitis, HIV and HTLV testing undertaken through a network of 24 laboratories across England for 2011, and trends in testing from 2008 onwards.

HPA: New research explores driving forces behind HIV epidemic in men who have sex with men in the UK. New HIV infections rose in men who have sex with men (MSM) between 1990 and 2010 in the UK, driven by a 26 per cent increase in the proportion having condomless sex, according to new research by the Health Protection Agency and UCL. However, the findings suggest the increase in new infections would have been 68 per cent greater without the introduction of antiretrovirals (ART) in the same period, and 400 per cent greater if MSM condom use had ceased entirely from 2000 onwards. 

International Dysphagia Diet Standardisation Initiative (IDDSI). The IDDSI aims to develop global standardised terminology and definitions for texture modified foods and thickened liquids for individuals with dysphagia of all ages, in all care settings, and all cultures. The website provides more details about what the challenge involves and describes the four stages of the initiative from December 2012 to December 2014. You can register to receive information about progress of the initiative.

Medicines and Healthcare products Regulatory Agency (MHRA): Medicines watchdog launches campaign. The Medicines and Healthcare products Regulatory Agency has launched a public health campaign in partnership with pharmacy organisations to highlight the need for the public to report any suspected side effects from medicines through the Yellow Card Scheme.
The Yellow Card Scheme

MHRA: MHRA concerned over increase in sales of unlicensed European medicines in the UK. The MHRA is seeing a growing number of reports involving unlicensed medicines originating from Poland and other Eastern European countries which are being offered for sale in a number of retail outlets throughout the UK.

Patient Safety First: Nutrition and Hydration week: a taste of patient safety. Information about the webinar sessions and simple activities to participate in during the week,18-24 March 2013, are now available.
Shared guides, tools and resources.

Patient Safety and Quality Healthcare: Nurse leadership from bedside to boardroom. There is increasing recognition that nurses must be involved as leaders and decision-makers throughout healthcare, not just at the bedside or within the nursing community.” [American article].

Regulation and Quality Improvement Authority (RQAI): Overview of safeguarding arrangements for children and vulnerable adults in mental health and learning disability hospitals (PDF 613KB). RQIA’s review has found that while robust policies and procedures for safeguarding are in place across Northern Ireland, these are not always consistently and appropriately applied. The review, based on inspections of 33 wards, makes 26 recommendations for improvement to ensure the safety and wellbeing of this particularly vulnerable group.

Royal Pharmaceutical Society (RPS): Paracetamol research shows it's time to change the law. New research published in the BMJ shows that limiting paracetamol pack sizes has reduced the number of deaths through overdose.  The Royal Pharmaceutical Society is now calling for legislation to stop retailers offering multi-buy deals on paracetamol.
BBC Health: Fall in paracetamol deaths 'linked to pack limits'.
BMJ: Long term effect of reduced pack sizes of paracetamol on poisoning deaths and liver transplant activity in England and Wales: interrupted time series analyses.

Scottish Government: UK Pandemic Influenza Communications Strategy 2012. This strategy provides an updated communications framework for the 4 UK administrations' response to an influenza pandemic. It builds on the 2008 pre-pandemic strategy and the lessons learned from the evaluation of communications activity during the H1N1 (2009) Influenza Pandemic. It is a companion document to the UK Influenza Pandemic Preparedness Strategy, published in November 2011.

Welsh Government: Working together to reduce harm – substance misuse delivery plan 2013-2015. The third delivery plan of the Welsh Government’s 10 year Substance Misuse Strategy sets out the actions to be taken nationally, regionally and locally to reduce the harm caused by drug and alcohol misuse. Actions over the coming three years include the development of a specific route to treatment for veterans, a plan for responding to the threat of new and emerging trends in substance misuse and better integrated care pathways for substance misuse service users.
News: Priorities for tackling substance misuse in Wales published.

World Health Organization (WHO): African Partnerships for Patient Safety (APPS): New Series of Resources and Tools – A framework for action. African Partnerships for Patient Safety (APPS), part of the WHO’s Patient Safety programme has launched a series of resources and tools that have been developed for patient safety improvement activity in the context of an African hospital. The programme catalyses improvements in patient safety through the use of hospital-to-hospital partnerships and facilitates spread of patient safety improvements across and between countries.