Patient safety updates - 7 March 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.

Agency for Healthcare Research and Quality (AHRQ): Making Health Care Safer II. An Updated Critical Analysis of the Evidence for Patient Safety Practices. This evidence report updates the 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices.” The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.”
Executive summary.
Evidence report (PDF 10MB).

AHRQ Patient Safety Network: Detection of Safety Hazards. Patient Safety Primers provide up-to-date summaries of key concepts in patient safety. Despite much effort, health care institutions are still searching for optimal methods to identify underlying system defects before patients are harmed and, when errors do occur, methods to recognize them as rapidly as possible to prevent further harm. This Primer reviews both prospective and retrospective methods to identify safety hazards that can lead to errors and adverse events (American).

American Medical Association (AMA): Safe Care Transitions: What Role for Ambulatory Practices? Report from the American Medical Association expert panel that presents the consensus views of a set of experts on how ambulatory practices should be optimally engaged in ensuring safe care transitions for patients entering and leaving the inpatient setting. The panel agreed on 5 tasks that need to be accomplished for safe care transitions and articulated 5 principles to help guide ambulatory practices in these tasks.

DH: Controlled drugs (supervision of management and use) regulations 2013: response to the consultation. This consultation response document summarises comments and views received concerning the overall governance of controlled drugs in the community and outlines what changes have been made to the 2006 regulations as a result.

DH: Act FAST shows anyone can be a stroke saver. The Act FAST campaign, which aims to raise awareness of the signs of stroke, is being aired again. The advert shows the symptoms we should look for to identify someone suffering from a stroke, making everyone a potential stroke saver.

DH: Red Tape Challenge: the controlled drugs (safe management and use) regulations 2006. This is the Department of Health's final response to the Red Tape Challenge, a public review of all domestic secondary regulations affecting business, civil society organisations or citizens in England.

Fierce Healthcare: 4 awesome infection-prevention videos. The editors at American website FierceHealthcare compiled this short list of “four healthcare provider videos that go above and (way) beyond to inspire their employees to join the fight against infections. From flash mobs to musical dream sequences, these videos make this very serious issue fun and, more importantly, memorable.”

Healthcare Inspectorate Wales: National Preventive Mechanism Publishes Annual Report into UK Detention: Concerns about use of Restraint. The third annual report of the UK’s National Preventive Mechanism (NPM) is published today, giving an overview of the state of detention in prisons, police custody, court cells, customs custody facilities, children’s secure accommodation, immigration, military and mental health detention.

Health Foundation: Lining up: how is harm measured. This learning report looks at lessons from the Health Foundation’s investigation into interventions to reduce central line infections and describes findings that have important implications for measurement of performance, and using measurement to improve quality and ensure patient safety. By observing implementation of a nationally organised infection control programme, the Lining Up research team discovered how organisations go about interpreting data definitions, collecting data and reporting results. "Apparently straightforward measurement tasks were found to be highly complex and subject to a range of human factors that rendered them so inconsistent as to undermine comparisons between organisations. This implies that policy makers need to be cautious about attaching incentives and penalties to findings reported for performance management purposes".

Health Foundation: What we know about how to improve quality and safety in hospitals. In this audio slideshow Professor Mary Dixon-Woods looks at improving the quality and safety of care in hospitals, and suggests that we need to take a three-pronged approach: ensuring we are collecting the right data and interpreting it intelligently, looking at the systems we work in and finally how culture and behaviour impact on quality of care.

Health Foundation: Mike Durkin: improving patient safety. Audio clip - Mike Durkin, Director of Patient Safety NHS Commissioning Board, talks to Elaine Maxwell about the challenges for improving patient safety in the NHS following the Francis Inquiry.

Health Foundation blog: Learning from failure. ‘The strength of an organization is measured not by counting the number of successes, but by its response to failure.’ 

Health Protection Agency (HPA): Pandemic flu vaccination linked to narcolepsy in UK children. Health Protection Agency scientists have found evidence of an association between Pandemrix flu vaccination and narcolepsy in children in England, according to the findings of a study published in the British Medical Journal. These findings are consistent with previous studies from Finland and Sweden which identified a similar association.
BMJ: Risk of narcolepsy in children and young people receiving AS03 adjuvanted pandemic A/H1N1 2009 influenza vaccine: retrospective analysis.

HPA: New action plan launched to combat emerging threat of untreatable gonorrhoea in England and Wales. The first Gonorrhoea Resistance Action Plan for England and Wales has been published recommending a heightened national response to combat this serious threat.

HPA: Cases of whooping cough continue to decrease: 1 March 2013. Confirmed cases of whooping cough in England and Wales have continued to decrease with 668 cases reported in January 2013, compared to 835 cases in December 2012. This will be the third month running that cases have decreased, however numbers remain unusually high following a sustained outbreak during 2012 which saw a record 9,741 cases.

HPA: HPA issues guidance for pet rodent owners following recent cases of hantavirus. The Health Protection Agency has issued new guidance for owners of pet rodents following two recent UK cases of hantavirus which are described in a paper published in Eurosurveillance. Hantaviruses are passed from rodents to humans through inhalation of infected animal waste including urine, faeces and saliva (usually through a bite), but prolonged exposure is required with infected rodents for the virus to be passed to people. Hantavirus infection does not pass from person-to-person.
Hantaviruses. This page includes the guidance Reducing the risk of infection from pet rodents. Eurosurveillance: Pet rats as a source of hantavirus in England and Wales 2013.

Health Protection Scotland: Continued Improvements in Antimicrobial Prescribing in Scotland. This fourth annual report on antimicrobial use and resistance in humans brings together prescribing and resistance data from 2011. The evidence shows that antimicrobial stewardship efforts, where both antibiotics and antibacterials are carefully managed to avoid the development of resistant infections, are having a positive effect in Scotland.

Health and Social Care Information Centre (HCSIS): Abuse of vulnerable adults in England - 2011-12, Final report, Experimental statistics. This report contains information on alerts and referrals to adult social care safeguarding teams in England derived from the Abuse of Vulnerable Adults (AVA) data collection for the period 2011-12. It presents a variety of information on aspects of the safeguarding process. In 2011-12, a total of 136,000 safeguarding alerts, 108,000 safeguarding referrals and 86,000 completed referrals were reported for vulnerable adults aged 18 and over in England.

Healthcare Improvement Scotland: Scottish Patient Safety Programme: Patient safety – it’s no trouble at all. The aim of the Programme is to reduce the number of events which could cause avoidable harm from healthcare delivered in any primary care setting. The programme will provide access to tools, resources and learning which will help you directly influence patient safety within your primary care setting. A summary booklet with information on the programme and its aims can be downloaded. National launch event. Implementation of the SPSP-PC will launch on 14 and 15 of March 2013 with a National Event held at Edinbugh Conference Centre, Heriot-Watt University.

International Council of Nurses (ICN): Adult and childhood immunisation 2013 revised edition (PDF 564.6KB). This publication aims to provide up-to-date information to nurses and other health professionals on three topic areas: how vaccines work and the value, safety and cost-effectiveness of vaccination; adverse events following immunisation, exploring common errors which can lead to AEFI and how to report and minimise AEFI; safe immunisation practices, covering auto-disable syringes; counterfeits, cold chain management and waste management.

ISD Scotland: Hospital Standardised Mortality Ratios. “Across Scotland there has been a 12.4 per cent reduction in deaths – equating to over 8,500 lives saved – since the introduction of the world-leading Scottish Patient Safety Programme in 2008”.
Scottish Government: Hospitals safer than ever.

Patient Safety First: Nutrition and Hydration week: a taste of patient safety. Information about the webinar sessions and simple activities to participate in during the week,18-24 March 2013, are now available.
Shared guides, tools and resources.

Scottish Government: Food standards body. Following the UK Government’s decision to reduce the scope of the UK-wide Food Standards Agency, an independent review panel was convened in Scotland, which recommends that a new body for food safety, food standards, nutrition, food labelling and meat inspection be created in Scotland.  A consultation on the roles, responsibilities and functions of Scotland’s new food safety body has been announced. 
A healthier Scotland: consultation on creating a new food body. The consultation runs for 12 weeks.

US Joint Commission: Transitions of Care Portal. The US Joint Commission has established this site with resources for clinicians and patients to help achieve safe care transitions.