Patient safety updates - 29 November 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.

1000 Lives Plus (2012) Achieving high reliability in NHS Wales. This is the latest white paper from 1000 Lives Plus. It draws on technical theory and practical work from the NHS and other industries to explore how 'high reliability' could make NHS Wales a better and safer place to both work and be a patient in. The white paper includes a driver diagram that identifies the five key areas NHS Wales organisations need to consider when seeking to achieve high reliability: effective engagement; looking beyond the simple and obvious; learning from failure; valuing expertise and promoting situational leadership and organisational reflection.
Health Foundation: Achieving high reliability in NHS Wales.

BBC: Secret Scottish NHS incident reports released. Hundreds of previously secret NHS reports into serious incidents, including 105 deaths, have been published by BBC Scotland.

Becker’s Hospital Review: 6 steps to encourage patient safety innovation at hospitals. This American posting on Becker’s Hospital Review describes steps that the Henry Ford Health System recommend hospitals can take to drive innovation in patient safety. In summary, the steps are: create a robust patient safety programme; develop a culture of safety; hold people accountable; pilot programmes; partner with researchers and participate in outside patient safety programmes.

BMC Health Services Research: Developing consensus-based policy solutions for medicines adherence for Europe: a delphi study. "Non-adherence to prescribed medication is a pervasive problem that can incur serious effects on patients' health outcomes and well-being, and the availability of resources in healthcare systems. This study aimed to develop practical consensus-based policy solutions to address medicines non-adherence for Europe".

BMC Health Services Research: An exercise intervention to prevent falls in Parkinson’s: an economic evaluation. The study compared the costs and cost-effectiveness of a targeted exercise programme with usual care for PwP at risk of falling. The authors of the study found no difference between groups in total healthcare, total social care cost and QALYs, but analyses indicate that there is high probability that the exercise intervention is cost-effective compared with usual care.  A larger trial-based economic evaluations over a longer term is recommended to confirm results.

BMC Health Services Research: Improving HIV outcomes in resource-limited countries: the importance of quality indicators. “This study concludes that an evidence-based set of program-level quality indicators is critical for the improvement of HIV care in resource-limited settings. These performance indicators should be utilized as treatment programs continue to grow.”

BMC Nursing: Peri-operative nurses' knowledge and reported practice of pressure injury risk assessment and prevention: A before-after intervention study. " The purpose of this study was to evaluate the effect of a multifaceted intervention on peri-operative nurses' (a) knowledge of pressure injury risks, risk assessment and prevention strategies for patients in the operating suite; and (b) reported practice relating to risk assessment practices and implementation of prevention strategies for patients in the operating suite."

DH: Antibiotic resistance poses alarming threat. Antibiotic resistance is one of the greatest threats to modern health and poses a future without cures for infection if antibiotics are not used responsibly, the Chief Medical Officer Professor Dame Sally Davies has warned in the lead up to European Antibiotic Awareness Day (EAAD).

DH: Winterwatch launches for 2012. Winterwatch has started regular updates about how the NHS is coping with the increased demands on its services in the cold winter months and weekly information on levels of flu-like illness and the uptake of flu vaccination.

DH: New vaccine to help protect babies against rotavirus. A new vaccination programme, planned to begin in September 2013, will see children under 4 months vaccinated against the highly infectious rotavirus. Causing around 140,000 diarrhoea cases a year in the under-5s, rotavirus leads to hospital stays for nearly 1 in 10 (around 14,000) of those who get it in the UK.

European Commission Public Health: Report from the Commission to the Council on the basis of Member States’ reports on the implementation of the Council Recommendation (2009/C 151/01) on patient safety, including the prevention and control of healthcare associated infections (PDF 106KB). This document focuses on the state of implementation of a number of actions to increase patient safety agreed to by the EU's member states in 2009. The report concludes that Member States have implemented various measures such as embedding patient safety in public health polices and identifying competent authorities on patient's safety; however more effort is needed towards actions targeting patients, e.g. patient empowerment, and health professionals, e.g. more education and training.

Health and Social Care Information Centre (HSCIC): NHS immunisation statistics – England, 2011-12. The report shows that nine out of 10 children in England in 2011-12 had been immunised against measles, mumps and rubella (MMR) by their secod birthday – the highest recorded coverage since 1997-98.
News: MMR vaccine: coverage for young children by age two at highest level in 14 years. 

Health Protection Agency (HPA): Top ten facts about antibiotics and antibiotic resistance. To mark European Antibiotic Awareness Day (EAAD) on November 18 Professor David Livermore, an international expert on antibiotic resistance and the HPA’s lead in this key area has devised his top ten facts about antibiotic resistance and antibiotics. 
Why your doctor didn’t give you antibiotics today. A new Antibiotic Awareness leaflet [external link] has been produced to encourage patients visiting their doctor with cold and flu symptoms not to ask for antibiotics for their treatment.
Antibiotics and you.
Health Protection Scotland: Get well soon – without antibiotics. Leaflets and posters available.

HPA: Survey shows use of antimicrobial stewardship toolkit leads to reduction in inappropriate prescribing in hospitals. A recent survey has shown that the Start Smart Then Focus (SSTF) antimicrobial stewardship resource, published last November, has helped improve prescribing practice in hospitals. Seventy-five Acute Hospital Trusts responded to a survey on the implementation of the toolkit. Of those who had formally or informally assessed the programme between 65 and 75 per cent said it had led to a reduction in the use of broad spectrum agents and between 77 and 85 per cent a reduction in inappropriate prescribing.

HPA: Reducing the risk of carbon monoxide poisoning over winter. To mark the start of Carbon Monoxide Awareness Week, the Health Protection Agency is advising people to have their fossil fuel and wood burning appliances checked by an appropriately registered engineer before the winter sets in.

HPA: HIV in the United Kingdom: 2012 report. HIV infection has been transformed from a fatal to chronic life-long infection due to the introduction of effective antiretroviral therapy (ART) in the mid-1990s. Consequently, the number of people living with diagnosed HIV has risen year on year, with an increase in number of new diagnoses among men who have sex with men (MSM) and people born in high prevalence countries.
News. HPA welcomes national HIV testing week as new data show quarter of people living with HIV remain undiagnosed in UK.

Medicines and Healthcare products Regulatory Agency (MHRA): Consultation on the revision of European legislation on medical devices. This consultation seeks the views of healthcare professionals, patients, industry, academics, and the interested public on the draft new European legislation on medical devices. It sets out the MHRA's view on the different changes suggested by the European Commission, and invites opinion on the potential impact of the new legislation as well as how it could be improved. Comments are invited until the 21st January 2013.

National Treatment Agency for Substance Misuse: Club drugs: emerging trend and risks (PDF 1.1MB). While overall drug use has declined in England, there has been an increase in those needing treatment for ‘club drugs’ such as ketamine and mephedrone in the last six years".  Club drug users make up just two per cent of adults in treatment and ten per cent of young people in specialist services.
News. Club drug users warned as new figures show more getting help.

Royal College of General practitioners (RCGP): TARGET (Treat Antibiotics Responsibly, Guidance and Education Tool): Antibiotics toolkit. The RCGP has launched a toolkit containing new guidance for GPs and their patients on the appropriate prescription of antibiotics. The guidance provides "a simple, effective, and cost-effective approach to the treatment of common infections to minimise the emergence of bacterial resistance in the community". 
News. RCGP TARGETs antibiotics prescribing.

RCN: Patient safety and human factors: The RCN has launched a new patient safety and human factors resource. This area of the RCN website looks at the way certain “human factors” including communications and teamwork play a crucial part in day to day delivery of healthcare. The negative effects of these can be reduced by evidence-based tools and interventions. The website identifies the tools and how they are being used to develop more safety conscious health services. The website complements the online learning 'Making sense of patient safety' that uses clinical scenarios to show the role nursing teams can play in protecting patients from harm.

World Health Organization (WHO): Safe Childbirth Checklist Collaboration. WHO has launched the Safe Childbirth Checklist Collaboration which aims to bring together a group of institutions and other interested partners to explore implementation and usability of the Safe Childbirth Checklist, in a range of different contexts. WHO is inviting health-care, research or academic institutions and others who are interested in improving maternal and child health, to participate in the Collaboration. 
See: Safe Childbirth Checklist.