Patient safety updates - 25 October 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): Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals. The Agency for Healthcare Research and Quality has produced this guide and corresponding TeamStepps module address how to improve care for patients with limited English proficiency (American).

AHRQ Perspectives on safety: Designing for safety -  In Conversation With... John G. Reiling, PhD. Dr. Reiling consults with hospitals nationwide regarding facility designs that emphasize safety, error reduction, and quality (American).

AHRQ Perspectives on safety: The Physical Environment: An Often Unconsidered Patient Safety Tool. This piece discusses how environmental factors contribute to adverse events in health care and describes how evidence-based design principles can improve safety (American).

AHRQ: Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship. This American toolkit will help facilities implement an antimicrobial stewardship programme that specifically targets C. difficile. The online toolkit includes includes an extensive list of user-ready resources and real world examples of how to use them. The toolkit is structured to address detailed questions that hospitals commonly have when considering how to set up an ASP, such as “Is my organization ready?” and “How do I select the right intervention?”.

AHRQ: Pharmacy Survey on Patient Safety Culture. This American toolkit will help community pharmacies assess their culture of patient safety. It is the latest survey in AHRQ’s suite of patient safety culture surveys now being used by hospitals, nursing homes and medical offices. The new survey is designed for pharmacy staff, including clerks, technicians and pharmacists. It includes 36 survey items that measure 11 areas of patient safety culture such as physical space and environment, patient counselling, communication about prescriptions across shifts, and teamwork. It also includes items about the frequency of documenting mistakes and an overall rating on patient safety.

AHRQ: Improving the measurement of surgical site infection risk stratification/outcome detection. The purpose of this American project was to explore opportunities for enhancing the detection and surveillance of inpatient-acquired surgical site infections (SSIs) for four target procedures—herniorrhaphy, coronary artery bypass graft (CABG), and hip and knee arthroplasty (including primary total arthroplasty, primary hemiarthroplasty, and revision procedures. One key activity involved developing and testing a computer-assisted algorithm for retrospective assessment of medical records, laboratory test results, and patient demographic data to identify electronically patients with potential SSIs. 

BBC: Concern raised about finance scheme for malaria drugs. The Global Fund to Fight Aids, TB and Malaria was introduced three years ago. "Oxfam says there is no evidence the programme has saved the lives of the most vulnerable people."

DH: Hillsborough: the report of the Hillsborough Independent panel. Sir David Nicholson has written to NHS organisations to ask them, in the light of the report of the Hillsborough Independent Panel, to review, with their Boards, their arrangements for responding to major incidents and take any appropriate action to ensure their current practices and processes are as robust as possible.

DH: Health reminded to get flu jab. Health staff are being reminded to get vaccinated against flu to cut the risk of it spreading to patients and colleagues this winter. Frontline healthcare workers are more likely to be exposed to the influenza virus, particularly during winter months when some of the people in their care will be infected. It has been estimated that up to 1 in 4 healthcare workers may become infected with influenza during a mild influenza season, a much higher incidence than expected in the general population.

DH: New checks for doctors in world first patient safety boost. Doctors in the UK are to become the first in the world to have regular assessments to ensure that their training and expertise are up-to-date and that they are fit to carry out their roles, Health Secretary Jeremy Hunt have announced. The General Medical Council will work with employers to implement and manage the system.
DH: Medical revalidation of doctors to start in December.

Global Handwashing Day: Global Handwashing Day was originally created for children and schools,but can be celebrated by anyone promoting handwashing with soap. Each year on October 15,  over 200 million people are involved in celebrations in over 100 countries over the world. The website provides tools and templates, and a video and photo library.

Health in Wales: Don’t ignore their wishes’ for a Fresh Start. The next phase of the Welsh Government’s three-year campaign to reduce children’s exposure to second-hand smoke in the car has been launched. The campaign encourages parents and relatives to stop smoking around young people, especially in enclosed spaces like cars.

Health in Wales: New powers to protect adult victims of suspected abuse. The Welsh Government intends to bring forward its proposals when the Social Services and Well-being Bill is introduced in January next year. The proposed power would enable social services to enter a property to speak to someone they think could be at risk of abuse or neglect, without interference from others in the house who might obstruct access. 

HPA: HPA hopes to set a new Guinness world record. HPA supported an attempt to set a new Guinness World Record which was that 1000 pupils across at least ten venues would do the same lesson at the same time - a lesson designed by e-Bug, a Europe-wide antibiotic and hygiene teaching resource which is led by the HPA.

Health Protection Agency (HPA): Salmonella found in liquid egg product. The Health Protection Agency has seen seven cases of Salmonella Enteritidis PT1 following consumption of a pasteurised liquid egg product which was sold through Myprotein® and Nutri Centre websites and Nutri Centre stores.

Institute for Healthcare Improvement (IHI): How-to Guide: Prevent Obstetrical Adverse Events. This How-to Guide describes the essentials elements of preventing obstetrical adverse events, including the safe use of oxytocin and key evidence-based care components in the IHI Perinatal Bundles: IHI Elective Induction Bundle (Oxytocin), IHI Augmentation Bundle (Oxytocin), and the IHI Vacuum Bundle. The guide describes how to implement these interventions and recommends measures to gauge improvement.

International Day for Disaster Reduction: This was held on 13 October 2012 and highlighted the need for women and girls to be at the forefront of reducing risk and managing the world’s response to natural hazards.
HPA press release. The Health Protection Agency highlighted the day and associated resources.

National Voices: Not the Francis Report (PDF 233KB). This report calls for greater urgency in improving patient safety and care quality. It warns that delays to the Francis Report could also create delays on improvements in care quality in the NHS and the report makes a number of recommendations for improving patient safety and the quality of patient care. These recommendations include greater patient and public involvement; the reorganisation of hospital services; and a drive towards integrated primary care.
Press release: Not the Francis Report. How to ensure Safety & Quality and prevent another Mid Staffs.

RCN: The role of a link nurse in infection prevention and control (IPC): developing a link nurse framework (PDF 232.9 KB). Link nurses (LNs) are commonly used to support many areas of specialist nursing practice within the UK. Practice areas which utilise LNs include diabetes, tissue viability, pain, nutrition and infection prevention and control (IPC). The RCN recognises the importance and popularity of LN systems in supporting clinical nurse specialists and IPC teams. This document forms part of a series of resources to support LNs, specialist teams, and managers who may be using or considering a LN system and specifically outlines the benefits of implementing LN roles for IPC. It describes the development of a role framework and associated competences in this area, based on the contribution of specialist infection control nurses and practising/aspiring LNs. Although this work has originated from, and uses, IPC examples, the principles of this work are relevant to LNs working in all specialties and a generic role framework has been provided for reference and adaptation (see Appendix 1).

RCN: Infection prevention and control commissioning toolkit (PDF 627.6 KB). Joint publication with the Infection Prevention Society (IPS) Reducing health care associated infections (HCAIs) remains high on the Government's safety and quality agenda and in the general public's expectations of quality of care. Since 2008, there has been a legal requirement on all NHS organisations to implement the Health and Social Care Act (2008) and the Code of Practice for the NHS on the prevention and control of HCAIs. This toolkit, developed collaboratively with the IPS, provides information for professionals in England involved in the commissioning of infection prevention and control services and forms the basis of an HCAI reduction plan for emerging commissioning organisations. It also suggests indicators to support performance management and assurance against provider contracts.
RCN: Renewed focus on infection prevention needed.

Regulation and Quality Improvement Authority (RQIA): Improvements noted in hospital hygiene practice. The RQIA has published its overview report of hospital infection prevention and hygiene inspections conducted during 2011-12. This overview report highlights the findings of 45 infection prevention and hygiene inspections in 85 hospital wards across 30 hospital sites in Northern Ireland. These inspections focus attention on the importance of good practice in areas such as hand hygiene, use of personal protective equipment, effective cleaning practices and decontamination of equipment in fighting health care associated infections.

World Health Organization (WHO): The Global Vaccine Safety Initiative (GVSI). The new Global Vaccine Safety Initiative (GVSI) web site is live as of 16 October 2012. The web site outlines actions that will be taken to achieve the eight objectives of the Blueprint – on vaccine safety monitoring, evaluation of safety signals, communication, internationally harmonized tools, regulatory frameworks, global technical support, expert advice, and interaction between stakeholders. 

WHO: WHO Patient Safety has launched a new document entitled Patient Safety Research: A guide for developing training programmes. Based on extensive consultation with key international experts in education and training, this comprehensive tool provides practical guidance for educators to develop training programmes in the field of patient safety research. The guide brings current concepts on curriculum building, as well as training and education to the field of patient safety research. It is designed to offer practical guidance to local educators developing their own training programmes – in accordance with their context-specific learning objectives.