Patient safety updates - 7 February 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.

AHRQ Patient Safety Network (PSNet): Engaging the Patient and Family in Safety. In Conversation with…Beverley H. Johnson. Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient- and Family-Centered Care. She talks about the interface between patient- and family-centered care and patient safety. (American).

AHRQ PSNet: Patient Engagement and Patient Safety. Saul N. Weingart, Vice President for Quality Improvement and Patient Safety at Dana-Farber Cancer Institute, highlights the advantages to and limitations of engaging patients in patient safety. (American).

BMC Health Services Research. Clinical risk management in mental health: a qualitative study of main risks and related organizational management practices. This qualitative study aimed to provide an overview of the most important clinical risks in mental health and related organizational management practices. It was carried out through in-depth expert interviews with professionals responsible for CRM in psychiatric hospitals. Interviews were transcribed and analyzed applying qualitative content analysis to thematically sort the identified risks.

Care Inspectorate: Report on the outbreak of E.coli 0157 infection. The report published by NHS Grampian Incident Management Team on the outbreak of E.coli 0157 in a nursery setting was published in May 2012. The care Inspectorate in Scotland is underlining the need for all care providers, service users and families, associated organisations and Care Inspectorate staff to read and learn from the report in order to help prevent infections in any care setting.

CERTAIN: Strong for surgery. A patient’s risk of negative outcomes from surgery can be improved by using best practices in the preparation for surgery. This American web site offers resources for both practitioners and patients to optimize safety through pre-procedure planning.

DH: Fire safety duties. This letter highlights the main findings from a report by the Fire and Rescue Service (FRS), into fire safety in the NHS. It follows a fire incident at a hospital in October 2011, as a result of which the FRS had planned to prosecute the NHS Trust concerned. It aims to address the safety concerns raised as well as the issue of criminal liability following NHS trust mergers.

DH: Estates and facilities alert. This alert relates to window restrictors that may be inadequate in preventing a determined effort to force a window open beyond the 100mm restriction. This follows an incident in which a patient died following a fall from a second floor hospital window. All healthcare organisations are asked to review the guidance.

Department of Health, Social Services and Public Safety (DHSSPS): New cervical screening test will benefit women. A test for the Human Papilloma Virus (HPV) has now been incorporated within the Northern Ireland Cervical Cancer Screening Programme with the aim of reducing the number of women who develop cervical cancer and to improve screening processes.

General Medical Council (GMC): Good practice in prescribing and managing medicines and devices. New guidance for doctors on how to prescribe medicine safely has been issued by the GMC and comes into effect on 25 February 2013. It "strengthens and broadens the current advice on prescribing medicines to include medical devices and gives key updates on using unlicensed medicines". It replaces the 2008 guidance and incorporates Remote prescribing via telephone, video-link or online published in 2012.
News: GMC issues new prescribing guidance. 

Health in Wales: E. coli O157 outbreak report published. The report into an outbreak of E. coli O157 associated with a Cardiff kebab shop in 2011 has been published. It sets out the multi-agency investigation of the outbreak which led to nine confirmed cases of E. coli O157, one of which involved the young victim being hospitalised and having to undergo dialysis as a result of the poisoning.

Health in Wales: Parents urged to vaccinate children after increase in measles cases. Public Health Wales is urging parents in the Swansea, Bridgend and Neath areas to get their children vaccinated with MMR following an increase in measles cases locally. There have been 112 notifications of measles in the Abertawe Bro Morgannwg University Health Board area since the beginning of November 2012.

Health Protection Agency (HPA): Cases of whooping cough decline after record numbers in 2012. The December figures show a decrease for the second month running in cases of whooping cough with 832 confirmed cases reported compared with 1,168 cases in November 2012.

Health Protection Scotland: Hand hygiene – 23rd bi-monthly audit report (PDF 1.2MB). Health Protection Scotland (HPS) has published the 23rd bi-monthly Compliance with Hand Hygiene - Audit Report as part of the National NHS Hand Hygiene Campaign. The report presents results from 14 NHS boards’ and two special NHS boards’ monitoring of staff compliance with hand hygiene.

Implementation Science: Improving physician hand hygiene compliance using behavioural theories: a study protocol. “Healthcare-associated infections affect 10% of patients in Canadian acute-care hospitals and are significant and preventable causes of morbidity and mortality among hospitalized patients. Hand hygiene is among the simplest and most effective preventive measures to reduce these infections. However, compliance with hand hygiene among healthcare workers, specifically among physicians, is consistently suboptimal”. This study identifies the barriers and enablers to physician hand hygiene compliance, and develops and pilots a theory based knowledge translation intervention to increase physicians' compliance with best hand hygiene practice.

Institute for Healthcare Improvement (IHI): Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. This article, from Healthcare Executive, describes a methodology that helps front-line staff to "see" patient safety problems in their systems and enables them to solve the problems and share that learning with others. "The methodology is constructed around an informal unit visit and designed to be a “conversation” about safety issues, versus an inspection or evaluation, with specific staff duties and desired outcomes also articulated". You need to log-in to the IHI website to access the article in full. 

Mid Staffordshire NHS Foundation Trust Public Inquiry: On 9 June 2010 the Secretary of State for Health, Andrew Lansley MP, announced a full public inquiry into the role of the commissioning, supervisory and regulatory bodies in the monitoring of Mid Staffordshire Foundation NHS Trust. The report of the full public inquiry into the failings at the Mid Staffordshire Foundation Trust was published on 6 February 2013. The inquiry, led by Robert Francis QC, looks at the role of commissioning, supervisory and regulatory bodies and why serious problems at the trust were not identified and acted on sooner. Abuse and neglect at the hospital has led to the unnecessary deaths of hundreds of patients. The report states that NHS Staff should face prosecution if they are not open and honest about mistakes and that "fundamental change" was need to prevent the public losing confidence in the NHS.
View the: Final report.

Social Care Institute for Excellence (SCIE): eLearning: Adult safeguarding resource. The resource explores the following questions: What is safeguarding? Who is an adult at risk? What is abuse? What are my responsibilities with regard to safeguarding? What can we do to prevent abuse of adults at risk?

Welsh Government: Patient Safety Wales. This website will provide information on how well each NHS Wales organisation is doing with implementing over 70 measures – called patient safety solutions – designed to improve safety and quality of care.  Data will be published each quarter. The patient safety solutions include a surgical safety checklist, hand hygiene amongst healthcare staff, medication safety and the colour coding of hospital cleaning equipment.

World Health Organization (WHO): Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2010 global survey. This report is the result of a global country capacity survey which assessed the the capacity of countries to respond to noncommunicable diseases (NCDs). The survey gathered detailed information about progress made in countries to address and respond to NCDs, and assessed their current strengths and weaknesses related to NCD infrastructure, policy response, surveillance and health systems response.