Patient safety updates - 2 May 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.

BBC Health: NHS 111 advice line ‘still fragile’. The new NHS non-emergency 111 telephone service in England is in a fragile state in a number of areas ahead of bank holiday weekend, NHS bosses admit.
BBC Health: Worcestershire withdraws NHS 111 advice line.
RCN: RCN comments on continued use of NHS Direct.

BBC Health: H7N9 bird flu is a 'serious threat' - researchers warn. The outbreak of a new type of bird flu in China poses a "serious threat" to human health, but it is still too soon to predict how far it will spread, experts have said.

BBC Health: More than million children at risk of measles. More than a million schoolchildren could be susceptible to measles due to the MMR vaccine scare, doctors have warned. They say a generation of unprotected children are now in secondary school, where they are at greater risk. Dr David Elliman, from the Royal College of Paediatrics and Child Health, said he was "surprised" outbreaks had not been more common. A large epidemic centred on Swansea has now affected 808 people.
Swansea measles: MMR schools vaccinations in west Wales.

Becker's Hospital Review: 50 experts leading the field of patient safety. Becker's Hospital Review has named "50 Experts Leading the Field of Patient Safety," which includes individuals at national organisations, universities and healthcare organisations working to improve patient safety. The patient safety leaders listed consist of advocates, professors, researchers, administrators and healthcare providers who have won awards, published articles, spoken out and led initiatives to reduce harm and ensure safety (American).

Care Inspectorate: Services for children and young people in the City of Edinburgh. The first in a series of reports examining how well services for children and young people are performing has been published. The Care Inspectorate was asked by Scottish Ministers to lead a new approach to inspecting services for children and young people, bringing together specialist teams from different inspection bodies.

DH: Management and decontamination of flexible endoscopes. This guidance (CFPP 01-06) offers best practice guidance on the management and decontamination of flexible endoscopes.

DH: Pertussis vaccine uptake in pregnant women February 2013. Statistics on the number of pregnant women having the pertussis (whooping cough) vaccine.

DH: Calculating MMR coverage: ready reckoner tool 2013. Tool for public health professionals to estimate coverage of the measles, mumps and rubella vaccination in their area. The ready reckoner tool is designed to allow local public health teams to estimate the current MMR coverage by age in their area, the current measles susceptibility, the numbers of unvaccinated children and the number requiring vaccination to reach 95%.

DH: Millions more protected against disease through improved vaccination programme. Millions more people will be protected against disease by improvements to the UK’s world class immunisation schedule, including three vaccination programmes to protect against flu, shingles and diarrhoea.

DH: Measures currently in place in the UK to reduce the potential risk of vCJD transmission via blood. There has been no evidence of any UK clinical cases of variant Creutzfeldt-Jakob Disease (vCJD) being linked to a blood transfusion given after 1999.

DH: Review of the Regulation of Cosmetic Interventions. The review found that, despite the popularity of non-surgical procedures such as Botox, dermal fillers or laser hair removal – which account for nine out of ten procedures in the UK – there is almost no regulation for them. This is despite the fact that they can have major, permanent effects on people’s health.
News story: Recommendations to protect people who choose cosmetic surgery.
BBC Health: Cosmetic crisis waiting to happen.
 
DH: Managing Healthcare Fire Safety. This guidance (HTM 05-01) sets out the Department of Health’s policy on fire safety in the NHS in England. It includes best practice guidance on management arrangements for fire safety.

DHSSPS: Minister announces new vaccination programme to protect children against vomiting and diarrhoea bug. Health Minister Edwin Poots has announced the introduction of a new childhood vaccination programme to protect children against the diarrhoea bug rotavirus.

Guardian: Cutting cord too early puts babies at risk says experts. Childbirth experts are urging the NHS to reverse the policy it has pursued since the 1960s of clamping and cutting a baby's umbilical cord as soon as it is born, citing mounting evidence that this may leave newborn babies deprived of vital blood from the placenta. Medical bodies, senior doctors and the National Childbirth Trust (NCT) want maternity staff to stop routinely clamping the cord within seconds of the baby's arrival and instead leave it untouched for anything from 30 seconds to whenever it stops pulsating naturally, usually within two to five minutes. National Institute for Health and Care Excellence is now reviewing its cord-clamping guidance, which it originally published in 2007.

Health Foundation: The measurement and monitoring of safety. 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; integration and learning. The Health Foundation is seeking the thoughts and insights of a wide range of stakeholders – from those with a specialist role in patient safety, those involved in direct care delivery, patients and carers and the public in general. Deadline for responses is 1 July 2013.

Healthcare Improvement Scotland: NHS Borders Management of adverse events review report. Reviewing NHS boards’ governance arrangements and processes for managing adverse events helps to identify whether appropriate learning and improvement is taking place to reduce the risk of events happening again. The reviews focus on the six key recommendations for NHS boards from the NHS Ayrshire & Arran report (2012) to provide assurance that NHS boards are effectively managing adverse events.

Institute for Healthcare Improvement (IHI): Ask Berwick. In a new series on the IHI Open School blog called 'Ask Berwick', Donald Berwick, IHI President Emeritus and Senior Fellow, and Former Administrator of the Centers for Medicare and Medicaid Services, will answer your questions (American).

NHS Employers: Healthcare Professional Alert Notices. An alert notice is the way that an NHS employer can make other bodies aware that a healthcare professional may pose a threat to patients or staff. A letter has been sent to trusts by Sir Bruce Keogh, medical director of NHS England setting out the interim arrangements for issuing alert notices via the NHS Litigation Authority who operate the alert notice system.

NHS England: NHS England urges parents to get their children vaccinated against measles. NHS England has joined with Public Health England, the Department of Health and local authorities across the country to urge parents of 10 - 16 year olds to prevent measles by getting their children vaccinated with the MMR jab. Published figures show high numbers of confirmed measles cases in England in the first three months of 2013 (587 by the end of March), following a record number of almost 2,000 cases in 2012. The rise in measles cases is mostly due to 10 - 16 year olds who missed out on vaccination in the late 1990s and early 2000s when concerns were raised by discredited fears of the MMR vaccine.
Public Health England: National MMR vaccination catch-up programme announced in response to increase in measles cases.
BBC Health: Measles vaccination plan in England targets one million children.

Nursing Times: Speak out Safely campaign. The Nursing Times has launched its Speak Out Safely (SOS) campaign to help bring about an NHS that is not only honest and transparent but also actively encourages staff to raise the alarm and protects them when they do so. This campaign aims to create an environment where it is safe to speak out and raise concerns within the organisation where nurses (and other staff) work, but also aims to offer protection to those who take their concerns externally when they find that necessary.

Public health England: National immunisation programme: planned changes for 2013 to 2014. This letter sets out planned changes to the national immunisation programme, with details of the specific programme for rotavirus for babies at 2 and 3 months.
 
Public Health England (PHE): Malaria cases fall across the UK. New figures from PHE on World Malaria Day show an overall decrease of 18% in imported malaria infections reported in the UK in 2012 (1,378) compared with 2011 (1,677). However malaria remains an important travel-associated infection, which particularly affects people travelling to visit friends and relatives, especially in Africa and Asia.

PHE: PHE welcomes changes to the UK vaccination programme. The Department of Health, Public Health England and NHS England have announced a series of changes to the current vaccination schedule to include three new vaccination programmes, which protect against flu, shingles and rotavirus, as well as updating the current meningitis C vaccine schedule.

Public Health England (PHE): Avian flu in China: guidance for health professionals. PHE has produced clinical guidance for health professionals on the assessment and investigation of patients with severe flu-like illness who have recently (within seven days) returned from China. The symptoms seen in these new cases of bird flu are similar to those seen in previous cases of avian flu. These include flu-like illness with high fever and cough which progresses to breathing difficulties, pneumonia and acute respiratory distress syndrome. Over 1,000 close contacts of confirmed cases of A/(H7N9) bird flu have been followed up and there is no evidence of person-to-person spread. The risk to the UK from this type of avian flu A(H7N9) is currently seen as being low.

PHE: Rotavirus: the green book, chapter 27b. Rotaviruses are ribonucleic acid (RNA) viruses that are contained within a protein capsule. Rotavirus strains are classified based on the outer layer proteins VP7 (G type) and VP4 (P type).

SCIE: Adult safeguarding elearning resource. This resource promotes the safeguarding of adults at risk. Dramatised video scenarios have been used to show how safeguarding issues can develop, and to suggest ways of dealing with them that protect people at the same time as preserving their right to make choices about their lives.
 
Whistleblowing Helpline: Support for whistleblowers. Bridging the gap campaign. Many people know about whistleblowing procedures at work, but some do not feel safe to use them. The Whistleblowing Helpline, which provides free, confidential and independent advice for those working in adult social care and the NHS, wants to change this. The Helpline’s 'Bridging the Gap' campaign aims to encourage a culture where all individuals feel safe to raise concerns and where managers are equipped to respond confidently and effectively.

World Health Organization (WHO): Clean Your Hands global campaign. For the fifth year, on and around 5 May, the WHO SAVE LIVES: Clean Your Hands campaign invites health-care facilities to celebrate hand hygiene promotion and improvement in health care. More than 15 600 health-care facilities from 164 countries worldwide are participating in this global campaign by committing to promote hand hygiene best practices. SAVE LIVES: Clean Your Hands draws global attention to the importance of hand hygiene to prevent the harm caused by health care-associated infections.

WHO: Vaccine safety events: managing the communications response. This manual provides practical, informative strategies and tools to help  plan and manage a communications response following a vaccine-related event (VRE) in a local community, at a national level, or beyond. It aims to teach immunisation programme managers how to use communications strategies and tools to increase public trust and confidence in vaccines, and to minimise the negative impact of VREs.