Patient safety updates - 8 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.

Agency for Healthcare Research and Quality (AHRQ) Perspectives in Safety: The evidence-based physical examination as a patient safety practice. This American article details the benefits of an evidenced-based approach to physical examination and diagnosis.

Center for Health Design: Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process (PDF 3.5MB). Report from a project aimed at establishing a consensus around patient safety issues to be considered during various stages in the healthcare design process and to identify key activities, methodologies, and tools for improving facility design in terms of patient safety. One of the key findings reported is that it is critical to focus on patient safety issues during the pre-design phase of a healthcare facility building project. This then affects all key decisions made in the project. High-priority design activities for patient safety identified include: articulation of project mission/vision, operational/future state planning, simulation, process-led design, measurable goals/metrics, ongoing check-in, post occupancy evaluation, and safety reviews. (American).

Department of Health, Social Services and Public Safety (DHSSPS): Children’s Social Care Statistics for Northern Ireland 2011/12. This new publication replaces and combines ‘Children Order Statistical Tables’ and ‘Children Order Statistical Trends’ for Northern Ireland. This change to our publications was implemented after public consultation and as a requirement to maintain designation as National Statistics following an assessment of children’s social care statistics for Northern Ireland by the UK Statistics Authority in March 2012.

DHSSPS: Protect Life Evaluation Report. An independent evaluation of the ‘Protect Life’ suicide prevention strategy says communities have an important role to play in reducing suicide rates. The findings of the evaluation highlight the continued importance of frontline services in helping those who are in serious emotional distress.  The report also reinforces the understanding that the long term reduction of suicide requires sustained and committed cross-departmental and cross-sectoral working to address the underlying social issues that contribute to increased risk.
News: Communities vital in reducing suicide rate.

DH: Updated never events policy framework and data published. The never events policy framework has been reviewed and updated in order to address areas of uncertainty and provide greater clarity about never events and the recommended response to them following feedback from stakeholders. It offers a useful reference for boards, clinicians, other staff and patients. The document also contains data on the number and types of never event reported in 2011/12 and 2010/11, revealing 326 never events were reported to strategic health authorities in 2011/12.

DH: Update to Green Book Chapter 25: Pneumococcal. Chapter 25 of the Green Book has been updated to reflect changes in the clinical risk groups that should receive the pneumococcal immunisation.

Greater New York Hospital Association (GNYHA): Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship. American toolkit designed to aid hospitals in reducing Clostridium difficile infections by developing a stewardship initiative to prevent antimicrobial misuse.

Guardian Healthcare Network: Patients need safe care 24 hours a day, seven days a week. “Fire services do not operate with slimmed down crews on Saturdays and Sundays, so why should hospitals?”  Views of Roger Taylor, Co-Founder and Director of Research at Dr Foster.

Health Foundation: Insight: a call for original research ideas. Insight is the Health Foundation's £1.6 million open call for original research proposals providing new knowledge on patient safety and patient-clinician relationships. Apply by 17 December 2012.

Health Protection Agency (HPA): HPA awarded £4 million contract by US government to develop next generation anthrax vaccine. The US Government, through the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, has awarded the Health Protection Agency (HPA) a contract worth £4 million ($6.5m) to develop a next generation anthrax vaccine at HPA’s facilities in Porton, Wiltshire, UK. The programme could be worth up to £14m ($24m) if all project milestones are met.

HPA: Case of Anthrax confirmed at Oxford. The Health Protection Agency (HPA) is aware that a person who injected heroin has been diagnosed with anthrax infection in Oxford. The patient is recovering. This case has occurred after two people who injected drugs died from confirmed anthrax infection in Blackpool within a month of each other in August and September this year.

HPA: Half of Legionnaires' cases in holiday makers. Around half (116) of the 235 cases of Legionnaires’ disease reported to the Health Protection Agency (HPA) in England and Wales in 2011 were in returning holiday makers. The annual number of Legionnaires’ cases has fallen from 355 cases in 2010, when around a third (114) were in returning travellers.

HPA: Safe supplies, new horizons. The NHSBT/HPA Epidemiology Unit collates and analyses data on infections in blood and tissue donors and blood recipients in the UK. In addition the unit provides a horizon scanning function for emerging infections. This year new data is presented for the bacterial screening of platelets and demographics of all individuals donating blood to NHSBT during 2011.

HPA: Scoping Health Risk Assessment for Beach Users at Dalgety Bay to Support Advice to Scottish Government Given in February 2012. A scoping public health risk assessment for beach users at Dalgety Bay was carried out at the request of the Scottish Government Health Department. It was recognised that the scoping assessment was being undertaken prior to sufficient data being available for a full public health risk assessment. The aim was to carry out a preliminary assessment of the possible health impact for people currently using the beach area in order to determine if any additional urgent actions were required, in addition to the restrictions on access to an area of the beach and advice to beach users that were put in place in the autumn of 2011.

HPA: Radon in Scottish Homes: Report of a Targeted Programme. This report details a programme, supported by funding from the Scottish Government, to identify homes with significantly elevated radon concentrations in the areas of Scotland with the greatest risk of high radon levels and, where high levels are found, to encourage the responsible person, normally the owner-occupier or landlord, to carry out remedial works. The three-year programme commenced in April 2009 and was initially based on the radon maps published at that time. An updated and more detailed radon map was published in July 2011 and the programme was modified to accommodate this.

HPA: Evidence on the Potential Health Impacts of Volcanic Ash. In recognition of the potential risk to the United Kingdom (UK) and Republic of Ireland (ROI), the Health Protection Agency together with national and international partners has set up a programme of work by which to ensure an effective response to any future volcanic eruptions.

Healthcare Improvement Scotland: Evidence note 47 for the Safety and risk associated with free standing midwife led maternity units. This evidence note describes the published evidence on the safety of freestanding midwife led maternity units as planned place of birth for pregnant women who are at low risk of birth complications. A large prospective observational study conducted in England between 2008 and 2010 formed the primary data source. 
Advice statement: Safety and risk associated with free standing midwife led maternity units.

Medicines and Healthcare products Regulatory Agency (MHRA): MHRA / NIBSC merger. On 1 April 2013 the National Institute for Biological Standards and Control (NIBSC), currently part of the Health Protection Agency (HPA), will officially become a new ‘centre’ of the Medicines and Healthcare products Regulatory Agency (MHRA) alongside the Clinical Practice Research Datalink (CPRD).

National Association of Healthcare Quality (NAHQ) Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems. The US National Association for Healthcare Quality has published this ‘Call to Action’ offering a framework to ensure the quality of reporting patient safety issues and that organisations respond appropriately.

Safe Care Campaign. This American website offers patient safety resources, including posters and videos with information on hand hygiene, infection prevention, and medication errors. The SAFE CARE Patient Safety Education programme was developed to assist (US) health care organisations in educating patients to help prevent medical errors. The goal of the program is to save lives, prevent harm and help patients receive safer care.