Patient safety updates - 24 January 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.

1000 Lives Plus: Providing assurance, driving improvement. The latest white paper from 1000 Lives Plus has collected information from across Wales about how mortality reviews have been used to monitor the quality of care and whether patients have been affected. All NHS Wales health boards and Velindre Cancer Centre are required to conduct mortality reviews. These reviews have helped to identify key themes that need to be addressed. “For example, we have been able to see opportunities to improve the co-ordination of certain kinds of illness like sepsis. We have also been able to improve the quality of record-keeping by seeing areas where information was missing and feeding that back to relevant members of the clinical team".

Agency for Healthcare Research and Quality (AHRQ): Standard written checklists can improve patient safety during surgical crises. In this study funded by the AHRQ, investigators simulated multiple operating room crises and assessed the ability of 17 operating room teams from three Boston area hospitals—one teaching hospital and two community hospitals—to adhere to life-saving steps for each simulated crisis. “When a checklist was used during a surgical crisis, teams were able to reduce the chances of missing a life-saving step, such as calling for help within 1 minute of a patient experiencing abnormal heart rhythm, by nearly 75 per cent”. An abstract of the study published in the New England Journal of Medicine is available, full text is available to subscribers.
New England Journal of Medicine: Simulation-based trial of surgical-crisis checklists.

British Medical Association (BMA): Drugs of dependence. The role of the medical professionals. The objectives of this report are to: encourage debate on the most effective approach to preventing and reducing the harms associated with illicit drug use and illicit drug-control policies, based on an independent and objective review of the evidence; examine the role of the medical profession in preventing and reducing the harms associated with illicit drug use and policies for control of illicit drug use; and encourage debate and dialogue between the medical profession and policy makers, legislators, the police, service providers and academics who have knowledge and expertise in this area. Includes links to executive summary and individual chapters.
Debate website: In depth: Drugs of dependence - the role of medical professionals.

BMC Health Services Research: The characteristics of patient safety culture in Japan, Taiwan and the United States. “Quality and safety issues are receiving growing attention. Patient safety culture (PSC) plays an important role in patient safety. The characteristics of PSC in various countries, each with a different set of values, have not been determined sufficiently. The aim of this study is to investigate the characteristics of PSC in Japan, Taiwan and the U.S.”

Department of Health, Social Services and Public Safety (DHSSPS): Advice to Pregnant Women during the Lambing Season. The advice says that pregnant women who come into close contact with sheep during lambing may risk their own health, and that of their unborn child, from infections that can occur in some ewes.

DH: Advice on preparation of formula milk restated. The Chief Medical Officer and the Director for Public Health Nursing have restated longstanding advice about the best practice when preparing formula milks, as set out by the Department of Health and the Food Standards Agency. "The department is aware that there has been debate over the preparation of formula milks using water at a temperature lower than 70°C. This is a concern because our precautionary approach sets out that people should make up formula milks using water at a temperature of 70°C, or above, to help minimise the microbiological risk to infants". The Chief Medical Officer and the Director for Public Health Nursing have asked relevant health professionals to continue to give this precautionary advice to parents.

DH: BHIVA and EAGA position statement on the use of antiretroviral therapy to reduce HIV transmission: January 2013. The Expert Advisory Group on AIDS (EAGA) has worked with the British HIV Association (BHIVA) to prepare this position statement to help clinicians and health promoters translate the evidence on HIV treatment as prevention and thus support patients to make an informed decision about starting treatment based on their individual circumstances.

Guardian: Antibiotic-resistant diseases pose 'apocalyptic' threat, top expert says. "Chief medical officer Dame Sally Davies tells MPs issue should be added to national risk register of civil emergencies".

Harm Free Care: NHS Safety Thermometer 2013/14 CQUIN guidance. The CQUIN guidance explains how the NHS Safety Thermometer can be used to achieve CQUIN goals for 2013/14, outlining a step-by-step process to help understand data, set improvement goals and measure improvement over time. To support the guidance, a number of resources have been made available including videos, data analysis, a CQUIN monitoring tool and a presentation on tips on everyday use of the NHS Safety Thermometer.

Health Foundation: Involving patients in improving safety: evidence scan. “Much is being done to improve safety in healthcare. Patients themselves can help to safeguard their own wellbeing and promote change. This evidence scan describes ways that patients have been involved in improving safety".

Health Protection Agency (HPA): HPA-led consortium successful in new €6m EU tender bid. The ‘Case studies, Exercises, LEarning, Surveys and Training across Europe (CELESTE)’ consortium led by the Health Protection Agency has been awarded the Multiple Framework Contract for ‘Scripting, planning, conduction and evaluation of exercises, training and assessment implementing the draft decision on cross-border threats to health’.

HPA: HPA update on seasonal norovirus activity: 15 January 2013. Latest figures from the Health Protection Agency (HPA) show there have been 4,407 laboratory confirmed cases of norovirus this season (from week 27 to week 01 2013). The latest figures are 56 per cent higher than the number of cases reported at this point last year, when there were 2,828 cases.

HPA: Flu activity – 17 January 2013. Latest figures from the Health Protection Agency (HPA) up to 13 January 2013 show that flu activity has decreased compared to the previous week based on a number of indicators, including GP consultation rates in England and the proportion of calls to NHS direct.

IHI: Prevent Surgical Site Infection for Hip and Knee Arthroplasty. IHI and its partners have assembled various tools and resources that can use to improve the safety of surgeries that are becoming increasingly common. These tools and resources include a How-to Guide. [American]
How-to-guide.
Project JOINTS. Project JOINTS (Joining Organizations IN Tackling SSIs) is an American initiative funded by the federal government to spread evidence-based practices to prevent SSIs after hip and knee replacement surgery. The Institute for Healthcare Improvement (IHI) provides Project JOINTS participants with free tools, resources, and special support to help implement these practices.

IHI Safety First Blog: Why Weight Watchers can teach us about medication adherence. In a new post to IHI's Safety First blog, Executive Director Frank Federico discusses how some of the ways Weight Watchers helps people lose weight might apply to helping patients with medication adherence. Federico and colleagues from Kaiser Permanente looked at the ways in which Weight Watchers approaches the crucial issue of motivation.

Mail Online: Shortage of nurses is 'killing thousands a year'. Patients in overstretched hospitals are developing fatal complications which could have been cured. Thousands of patients are dying in hospitals each year because there are not enough doctors or nurses, research done by Imperial College and the University of Southampton shows. The study found that "Patients are almost 10 per cent more likely to die if there are fewer medically-trained staff on wards".

New England Journal of Medicine: The future of antibiotics and resistance. An article in the perspective series and an audio interview with Dr Robert Moellering on the evolution of antibiotic resistance and strategies for combating it. These are freely available.

RAND Corporation: Hepatitis C: a projection of the healthcare and economic burden in the UK. Work presented in this report sought to assess the healthcare and economic burden of the hepatitis C virus (HCV) infection in the United Kingdom. This included exploring different scenarios projecting the impact of providing antiviral treatment to a larger proportion of persons with HCV infection from 2012 onwards.

RCN: Patient safety and human factors resource - additions. 

Welsh Government: New Welsh Government campaign highlights the dangers of ‘Meow Meow’. A new Welsh Government campaign aimed at highlighting the dangers of the drug Mephedrone, commonly known as 'Meow Meow', as well as other new and emerging drugs and the damage they can cause has been launched by the Health Minister Lesley Griffiths. Use of the Mephedrone has risen dramatically over the last six months and in particular during the last three months.

Welsh Government:  Changes to cervical screening in Wales announced. The Wales Screening Committee has considered and endorsed the  UK National Screening Committee (NSC) recommendations published last December to change the age that women receive their first invitation for cervical screening from 20 to 25, following a review of the latest evidence surrounding cervical screening.

Welsh Government: Food Hygiene Rating (Wales) Bill set to become law. Wales is set to be the first country in the UK to introduce a mandatory scheme requiring food businesses to openly display their hygiene rating.