Patient safety updates - 21 March 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 eBulletin: 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) Perspectives on safety: Update on simulation in health care. In Conversation With… David M. Gaba. American anesthesiologist David M. Gaba, helped introduce the modern full-body patient simulator and the concept of crew resource management training to health care.

AHRQ Perspectives on Safety: The literature on health care simulation education: what does it show? The education of health care providers is an integral part of patient safety. This American article discusses the value of simulation-based education in health care.

BBC 2 Horizon: How to avoid mistakes in surgery. BBC 2 Horizon is screening a programme on Thursday 21 March at 9.00pm about human factors in health care. The programme, presented by Dr Kevin Fong will look at how learning about the human in the system and the system itself can bring about enormous improvements in safety and outcomes that technology and medical science aspire to. The programme uses a tragic death to highlight human factors that all of us are prone to, and looks at how we can learn from others both in and outside healthcare to make a real difference in the future.

Care Inspectorate: Legionella bacteria prevention in water systems. The Care Inspectorate in Scotland are highlighting risks for Legionella. A review by the Health and Safety Executive (HSE) of recent Legionella outbreaks in Britain over the past ten years has shown poor control of water systems continues to create the risk of outbreaks.  Service providers must ensure that there are appropriate systems in place to prevent the potential contamination and growth of Legionella bacteria in their services. Information on all aspects of Legionnaires’ disease and how to properly manage the risks is accessible from the Health and Safety Executive (HSE) website.
HSE: Legionnaires' disease. The control of legionella bacteria in water systems. Approved Code of Practice and guidance.

Consumer Reports: Choosing wisely. Consumer Reports is working with doctors to help patients avoid unnecessary and potentially harmful medical care. Consumer Reports is also participating in the effort, by helping the medical societies produce videos and PDFs that doctors can share with patients about specific overused tests and treatments (American).

DH: Chief Medical Officer publishes volume 2 of her annual report. The second volume of Professor Dame Sally Davies the Chief Medical Officer’s annual report provides a comprehensive overview of the threat of antimicrobial resistance and infectious diseases. The report highlights that, while a new infectious disease has been discovered nearly every year over the past 30 years, there have been very few new antibiotics developed leaving our armoury nearly empty as diseases evolve and become resistant to existing drugs.

DH: Addendum to guidance for healthcare providers on managing Pseudomonas. The addendum builds on and supersedes the March 2012 guidance. The document is concerned with controlling and minimising the risk of morbidity and mortality due to P. aeruginosa associated with water outlets.

GE Reports: New patient safety survey: few nurses call their hospitals safe. According to a survey carried out by GE Healthcare and the American Nurses Association, 900 nurses from three countries -  America, Britain and China - feel that hospitals are falling short in keeping patients safe. "Although nearly all nurses said that their hospitals had in place programs that promote patient safety, they questioned their impact. Only 41 percent of nurses described the hospital they worked in as “safe” and fewer than 57 believed that the patient safety programs in their hospital were effective. They said access to technology, heavy workload, communication with patients and doctors, and punitive systems for reporting errors were at the core of the problem". 

Guardian: Mid Staffs tragedy could make the NHS stronger, says US expert. The Guardian reports that the NHS has the capacity to lead the world in patient safety if it learns from the Mid-Staffordshire tragedy, according to the US expert. Don Berwick, an acclaimed proponent of patient safety has been appointed by David Cameron to head a taskforce on improvements in the aftermath of the Francis report.

Guardian: Comment piece: Transparency in the NHS not only saves lives. The Guardian contains a comment piece by Tim Kelsey, director for patients and information at the NHS Commissioning Board; he talks about the importance of being  open about medical data to improve outcomes.

Healthcare Improvement Scotland: Launch of new Scottish Patient Safety Programme maternity care collaborative. "The Collaborative has the ambitious aims of reducing the number of avoidable stillbirths and neonatal deaths by 15 per cent and reducing the number of severe post-partum haemorrhages by 30 per cent by 2015".

Healthcare Improvement Scotland: Management of adverse events review reports. The Cabinet Secretary for Health, Wellbeing and Cities Strategy instructed Healthcare Improvement Scotland to conduct a rolling programme of reviews across NHS boards starting in autumn 2012. The reviews are aimed at: supporting health boards improve services by learning from adverse events; reducing the risk of these events happening again and providing public assurance that NHS boards are effectively managing adverse event. Reports have been published for four NHS Boards. There is also a learning and improvement report based on these first four reviews. 
Management of adverse events: Learning and improvement report March 2013.

Health Education England (HEE): Pledge on infection control training to improve patient care. Health Education England  has made a commitment to ensure that infection control is part of all of its funded courses to ensure improved quality of care for patients. The pledge follows publication of a report on antimicrobial resistance and infectious diseases from England’s Chief Medical Officer (CMO), Professor Dame Sally Davies.

Health Protection Agency (HPA): Study recommends changes to pneumonia prevention strategies. A Health Protection Agency report published has found that since 2000 the number of cases of Pneumocystis jirovecii pneumonia (PCP) has increased in England by an average of seven per cent each year. The findings of the paper suggest that further work is needed to re-assess the prevention strategies currently in place for dealing with this infection.  

HPA: Study shows poor hygiene practices at mobile vendors. Research from the Health Protection Agency has revealed that food, water, chopping boards, cleaning cloths and security wristbands sampled from mobile and outdoor food vendors were contaminated with a range of bacteria including E.coli. This bacteria, which originates from human or animal faeces, indicates either poor hygiene, undercooking or cross-contamination in the kitchen.

HPA: Human Radiosensitivity – RCE 21. The report concludes “that there is growing evidence from a range of sources for variation in radiosensitivity that can affect the risk of radiation-induced cancer or, at higher doses, tissue damage. A proportion of this range is likely to have a genetic origin but there is also substantial evidence for lifestyle factors, and particularly tobacco smoking, affecting individual risk”.
Press release: New report on human sensitivity to radiation.

HPA: Investigation into an outbreak of Cryptosporidium infection in spring 2012. The Health Protection Agency has confirmed that findings of an investigation into an outbreak of Cryptosporidium infection that affected around 300 people in England and Scotland in May 2012 showed strong evidence of an association with eating pre-cut bagged salad products which are likely to have been labelled as ‘ready-to-eat’.

Medicines and Healthcare products Regulatory Agency (MHRA): Medicines regulator implements innovative software to analyse risk data and target inspection activity. As part of its risk-based inspections regime which ensures compliance with statutory obligations relating to medicines, the MHRA is implementing new IT software. "MHRA inspections across all the disciplines will be better prioritised as a result, helping to target its activity to the areas of greatest risk and ultimately help protect public health".

National Patient Safety Foundation: Lucian Leape Institute: Through the eyes of the workforce: creating joy, meaning, and safer health care. This report focuses on the health and safety of the health care workforce and challenges health care organisations to initiate broad organisational changes in the belief that patient safety is inextricably linked to worker safety. The report recommends seven strategies (American).

Public health Wales: Measles cases pass 300 as outbreak continues to spread. Public Health Wales is renewing its plea to parents to ensure children are given the three-in-one measles, mumps and rubella (MMR) jab as cases in the outbreak centred on Swansea reach 316 with 64 new cases reported in the last week alone. The disease has now spread to children in 111 secondary and primary schools, nurseries and playgroups, increasing the likelihood that unvaccinated children will come into contact with those already infected.

Scottish Government: Leading the way on patient safety. GPs in Scotland are set to become even safer as the world’s first patient safety programme for primary care is launched. GPs and their staff will undertake safety surveys and case note reviews to increase staff awareness and integrate patient safety into their daily work to reduce avoidable harm. “Scotland will be the first country in the world to implement a national patient safety programme across the whole healthcare system".

University of Bristol: CIPOLD Confidential Inquiry into premature deaths of people with learning disabilities. The three year Confidential Inquiry has been led by academics at the University of Bristol and funded by the Department of Health. It was commissioned in 2010 following various reports by Mencap and other organisations who have been concerned about the unequal healthcare of people with a learning disability. 
Mencap: 1200 avoidable deaths. Research that Mencap commissioned from Professors Glover and Emerson of the Improving Health and Lives Learning Disabilities Observatory has found that 1,238 children and adults die across England every year because they are not getting the right health care. The research is a national estimate based on the findings of the Confidential Inquiry into premature deaths of people with a learning disability. 
Briefing about Confidential Inquiry.
BBC: Early death link to learning disabilities ‘shocking’. People with learning disabilities die on average 16 years earlier than they should, due to NHS failings, according to official research.

World Health Organization (WHO): Adequate treastment essential to stop tuberculosis across Europe - WHO/ECDC new report. Over 1000 patients are estimated to fall sick with tuberculosis (TB) every day across Europe – or over 380 000 yearly – signalling that there is no room for complacency when it comes to TB prevention and control. Marking World TB Day, the WHO Regional Office for Europe and ECDC today released new surveillance data for 2011. The data show that while overall the number of TB cases has come down at a rate of 5 per cent per year, countries in the eastern part of the WHO European Region bear 87 per cent of the burden. 
Tuberculosis surveillance and monitoring in Europe 2013.

WHO: Exploring patient participation in reducing health-care-related safety risks. This report presents an overview of the legal influences on patient safety and explores the relationship between patients’ rights, patient participation and patient safety. It provides a synthesis of studies of patient involvement, with detailed examples from Bulgaria, France, the Netherlands, Poland and Portugal. It highlights the need to strengthen a continuum of information between various levels of care, including patient experiences, health literacy and engagement.