Patient safety updates - 18 April 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 eBulletin: 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): In conversation with… Christopher P. Landrigan, MD, MPH. Christopher P. Landrigan has performed key studies on how sleep deprivation affects clinicians and strategies to mitigate such fatigue to improve patient safety, including seminal articles published in the New England Journal of Medicine in 2004 and 2010 [American].

AHRQ: Making Health Care Safer II. An Updated Critical Analysis of the Evidence for Patient Safety Practices. This American 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'. See: Executive summary (PDF 482KB).

AHRQ: Are residency duty hour rules improving patient safety? This article discusses evidence surrounding the impact of resident duty hour limits on safety in health care.

AHRQ: Stories of success: Using CUSP to improve safety. This American action guide contains the stories of four hospitals that have applied a patient safety model called the Comprehensive Unit-based Safety Program, or CUSP, to dramatically reduce central line-associated bloodstream infections (CLABSIs) and other health care-associated infections (HAIs). “These case studies illustrate how actual hospitals have applied CUSP to improve care. Each story is unique and detailed. We use quotations extensively because they give a human face to the principles and practices at the heart of the CUSP.”

BBC Health: Measles vaccine ‘should be mandatory’. An American doctor told the BBC that measles vaccinations should be mandatory in a bid to reduce the spread of the disease in South Wales. Dr Paul Offit, a measles expert, said a similar measure had worked in the US to halt an outbreak. The Welsh government has said a compulsory vaccination would damage the ‘hard won trust’ in the MMR vaccine.
DH: Measles at highest level for 18 years.
RCN: RCN praises ‘tireless’ work of nurses in Swansea measles epidemic.

Care Inspectorate: A report into the deaths of looked after children in Scotland 2009-2011. This report looks at the deaths of children looked after by local authorities. Any time a looked after child dies, local authorities must inform the Care Inspectorate, which is charged with reviewing the circumstances of the death.

DH: More infections becoming resistant to antibiotics. England's Chief Medical Officer (CMO) has added antibiotic resistance to the national risk register following the publication of the 'Annual Report of the Chief Medical Officer - Infections and the rise of antimicrobial resistance'. Its addition to the register means that this issue will be given full attention by politicians in England as well as the G8 and World Health Organization. Other risks on the register include pandemic flu, severe weather, attacks on transport and major industrial accidents. The dramatic rise in bugs that are resistant to antibiotics means there needs to be action not just from Government but also from healthcare institutions like hospitals, the pharmaceutical industry, patients and the general public.

DH: vCJD and transfusion of blood components: updated risk assessment. This risk assessment presents a mathematical model, primarily designed to examine how many future clinical cases might be caused in this way. Key inputs to the model include the number of donors that might be carrying Creutzfeldt-Jakob Disease (vCJD) infection without showing any symptoms, the infective dose in blood components sourced from such a donor and the likelihood of recipients surviving long enough to develop symptoms of vCJD if infected.

Health Foundation: Safer Patients Network evaluation. The Safer Patients Network was created as a way for participants in the Health Foundation’s Safer Patients Initiative to continue to engage with each other after the programme had ended. This independent evaluation of the Safer Patients Network aimed to determine to what extent it succeeded in transforming the Safer Patients Initiative from a successful collaborative to a self-sustaining, member-driven network committed to continually improving patient safety within the member organisations and beyond.

Health Foundation: The measurement and monitoring of safety. This framework provides a starting point for discussions about what ‘safety’ means and how it can be actively managed. This framework highlights the following five dimensions, which the authors believe should be included in any safety and monitoring approach in order to give a comprehensive and rounded picture of an organisation’s safety: past harm; reliability; sensitivity to operations; anticipation and preparedness and integration and learning.

Implementation Science: Explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial. Incorporating social learning theory, social influence theory, theory on team effectiveness, and leadership theory, this Dutch study used a cluster randomised trial to compare the effectiveness of a ‘state-of-the-art strategy’ with a ‘team and leaders-directed strategy’ for improving nurses’ compliance with hand hygiene guidelines.

Medicines and Healthcare products Regulatory Agency (MHRA): Medical devices regulator asks people with diabetes to check if they have faulty blood glucose meters. The Medicines and Healthcare products Regulatory Agency (MHRA) has asked people with diabetes to check if they have a specific type of blood glucose meter at home. A software fault causes two specific models to either turn off or give a false low reading in the event that the blood glucose level is extremely high.

NHS England: Phased resumption of children’s heart surgery at Leeds Hospital agreed. Children’s heart surgery at Leeds General Infirmary can begin a phased restart. It follows completion of the first-stage of a review by a multi-disciplinary independent clinical team, which has been working to establish the immediate safety of the unit. NHS England has accepted the Trust’s recommendation, supported by independent experts, that surgery should resume gradually over the next month, starting with lower-risk cases.

University of Leicester: Resources about H7N9 influenza. This avian influenza virus has recently been reported for the first time in humans. This page lists resources about this strain of avian influenza.