Patient safety updates - 27 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.

Care Inspectorate: Information about seasonal influenza and pneumococcal vaccination in residential care services. During the 2011/12 influenza season the Care Inspectorate in Scotland was aware of two care home services where some residents were given influenza vaccine twice. There were reports that some care home nurses were administering vaccine without the legal authority to do so or appropriate consent. This guidance provides information on how vaccines should be supplied and administered to children and adults in residential care services.

DH: Overview of the NHS Safety Thermometer and advice on the data collection is published. Following recent media interest, an overview of the NHS Safety Thermometer and some advice for the NHS on how they can help to provide an accurate interpretation of their NHS Safety Thermometer data for interested parties is published. NHS organisations who have been collecting data using the NHS Safety Thermometer have been seeking guidance on how to explain the NHS Safety Thermometer in general and their own data in particular. The purpose of this letter is therefore to provide an overview of the collection and advise the NHS how they can help to provide an accurate interpretation of their data for interested parties.

DH: Trusts and PCTs alerted to European Antibiotic Awareness Day materials. Chief executives of acute Trusts and PCTs are being alerted to a range of education materials that they can use in their local European Antibiotic Awareness Day (EAAD) campaigns and initiatives. EAAD, which takes place on 18 November 2012, raises public and professional awareness of the need for responsible prescribing to slow down the development of antibiotic resistance and is part of our national programme to combat antimicrobial resistance.

DH: Update to Green Book Chapter 8 and Chapter 34. Chapter 8: Vaccine safety and the management of adverse events following immunisation, has been updated to include a new section on Thiomersal. The details of suppliers of VZIG in England and Wales have been updated in Chapter 34: Varicella.

Department of Health, Social Services and Public Safety (DHSSPS): Co-operation key to protecting our children. Safeguarding children is everyone’s business and co-operation is vital. That was the message from Health Minister Edwin Poots today as he launched the new Safeguarding Board for Northern Ireland (SBNI). The Board includes membership from health and social care bodies, criminal justice agencies and Education and Library Boards. It will work to ensure the effectiveness of what is done by its member agencies to safeguard and promote the welfare of children.

DHSSPS: More inspections promised as DHSSPS officials seize banned sports supplement. Medicines Enforcement Officers from the Department of Health, Social Services and Public Safety have launched a crackdown on the sale of banned sports supplements. Following an inspection of a retail outlet in the Greater Belfast Area, officers seized quantities of Jack3D containing the stimulant DMAA (dimethylamylamine) recently banned by the Medicines and Healthcare products Regulatory Agency (MHRA) as unlicensed Medicinal products.

European Centre for Disease Prevention and Control (ECDPC): Introduction of HPV vaccines in European Union Countries (PDF 990.2KB). This updates the guidance published in 2008 based on research published since then which has filled some of the knowledge gaps. A human papillomavirus vaccine programme is implemented in 19 European countries.
Health Protection Scotland: ECDC guidance on HPV vaccination.

Health Foundation: Infection data may not be comparable across hospitals - but “gaming” is not the explanation, study shows. A new study funded by the Health Foundation and published in the US journal The Milbank Quarterly has found that some kinds of infection data may not be comparable across hospitals, and may not be suitable for use as a performance measure. Researchers found most variability arose for what they called “mundane” reasons. The study dismissed ‘gaming’ as the explanation for the variations the researchers found. 
Milbank Quarterly: What counts? An ethnographic study of infection data reported to a patient safety programme. Abstract only freely available.

Health Protection Agency (HPA): Acute respiratory illness associated with a new virus identified in the UK. The HPA has confirmed the diagnosis of one laboratory confirmed case of severe respiratory illness associated with a new type of coronavirus. The patient, who is from the Middle East and recently arrived in the UK, is receiving intensive care treatment in a London hospital. "Coronaviruses are causes of the common cold but can also include more severe illness, such as the virus responsible for SARS (Severe Acute Respiratory Syndrome). This new virus, however, is different from any that have previously been identified in humans".
BBC Health: New 'Sars-like' coronavirus identified by UK officials.

HPA:  Poisons experts issue warning about wild mushroom foraging. Wild food enthusiasts are being urged to take extra care when foraging for mushrooms because of the risk of picking toxic varieties, says the Health Protection Agency's poisons experts.

Implementation Science: A systematic review of hand hygiene improvement strategies: a behavioural approach. “Many strategies have been designed and evaluated to address the problem of low hand hygiene (HH) compliance. Which of these strategies are most effective and how they work is still unclear. This study describes frequently used improvement strategies and related determinants of behaviour change that prompt good HH behaviour to provide a better overview of the choice and content of such strategies.”

NHS Commissioning Board: Release of Organisation Patient Safety Incident reports. The figures show that the number of patient safety incidents in England that occurred between 1 October 2011 and 31 March 2012 and were submitted to the National Reporting and Learning System (NRLS) by 31 May 2012 was 612,414. This is an increase of 2.3 per cent compared to the previous reporting period (1 April 2011 to 30 September 2011.). 90 per cent of trusts in England submitted incident reports to the National Reporting and Learning System for this set of data.

Patient Safety First:  Safer Surgery Week: 24-30 September 2012. The week has been promoting local activities which are designed to help improve the quality and reliability of local implementation of ‘Five Steps to Safer Surgery’. A series of webinars has run throughout the week and recordings of those held earlier in the week are now available to view.

Social Care Institute for Excellence (SCIE): Safeguarding adults: Mediation and family group conferences. "Mediation and family group conferences are two methods used to try to empower people to work out solutions to their own problems. Mediation is usually a series of facilitated meetings where people agree to discuss areas of difficulty or dispute". SCIE’s report looks at research evidence about what works in mediation and family group conferencing.
At a glance 62: Safeguarding adults: Mediation and family group conferences. 

World Health Organization (WHO) Patient Safety: Patient Safety Research: A guide for developing training programmes. This guide, which was developed through an extensive consultation with key international experts in education and training, provides guidance to educators for the development of training programmes in the field of patient safety research.