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Found 176 results
  1. Content Article
    Sharps injuries (SI) and mucocutaneous exposures (MCE), collectively termed “blood and body fluid exposure” (BBFE), pose a diseases-transmission risk and a psychological stress to health care workers and a responsibility on employers to prevent their occurrence. However, little UK national data is published on their incidence.  The Royal College of Nursing (RCN) present results from a survey of their members.
  2. Content Article
    This systematic analysis in The Lancet used data covering 471 million individual records from systematic literature reviews, hospital systems, surveillance systems and other sources. The authors, an international research collective called the Antimicrobial Resistance Collaborators, used this data to estimate deaths and disability-adjusted life-years (DALYs) that have come about as a result of bacterial antimicrobial resistance (AMR). They estimated that, in 2019, 1.27 million deaths were directly attributable to AMR, with the three primary infections involved being lower respiratory and thorax infections, bloodstream infections and intra-abdominal infections. Their analysis shows that AMR death rates were highest in some lower- and middle-income countries, making AMR not only a major health problem globally, but a particularly serious problem for some of the poorest countries in the world.
  3. Content Article
    In this article in Becker's Hospital Review, Mackenzie Bean highlights five of the most pressing safety issues for healthcare systems and hospitals to address in 2022:Foundational safety workSupporting the healthcare workforceIntegrating equity into safety workDiagnostic harmHealthcare-associated infections
  4. Event
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    The aim of this webinar is to share, engage and discuss with clinicians, patient safety managers, patients and leaders the latest standards. There will be 2 sessions: 17.30: Session 1 – NatSSIPs 2: what it is and why it matters Welcome and introduction The CPOC perspective The Patient Safety Learning perspective Photo review of why NatSIPPs matters The patient perspective What is new in NatSIPPs 2? Resources to support Implementation: Checklists, infographics Q&A 18.30: Session 2 – NatSSIPs 2: implementation, practical insights and tips Our NatSIPPs 2 Workshop and how to consider a NatSSIPs gap analysis Team training for NatSIPPs 2 Q&A Register
  5. Event
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    This enlightening session during Wounds Week dives into the world of surgical infection prevention. The session will explore a range of assessment and improvement tools provided by the World Health Organization (WHO) that have a significant impact on infection prevention and patient outcomes. Claire Kilpatrick, Consultant, Global Health - KSHealthcare (S3Global), will guide you through an overview of various WHO tools that have been developed to guide healthcare practitioners in infection prevention practices. By examining these tools and understanding their significance, you will gain practical knowledge on how to implement effective measures that minimise the risk of surgical infections and enhance patient outcomes. Register
  6. Event
    When surgical site infection (SSI) rates began to climb at University of Wisconsin Health, a multidisciplinary group of surgical professionals assembled to drill down to the root causes of the infections. The Strike Team now has full authority to recommend changes to daily practices and retains final say in what must be done to improve patient care. Learn from the team’s evidence-based success by understanding how they use real-time data to identify gaps in care and implement proven protocols that improve infection prevention practices. Join a live webinar to discover: Evidence based successes in SSI prevention. How to use real-time data to identify gaps in care. Implementation strategies and protocols that improve infection prevention practices. Register
  7. Event
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    Chaired by Patient Safety Learning's Helen Hughes, and sponsored by BD, an expert panel will discuss what measures are needed to achieve transformational change in the way infection is detected, monitored, prevented, and managed across the NHS, healthcare systems and broader society. The session will touch on how industry, professional bodies and healthcare experts can work collaboratively to support the creation of a healthcare system which is resilient and mature in dealing with disease outbreak and pandemic preparedness, infection prevention, and rapid treatment of time-critical infection, ultimately delivering antimicrobial stewardship (AMS) and improved sepsis outcomes. What attendees will learn: Understand the current challenges and barriers to effective infection prevention. What the future of infection prevention and management looks like in a post-COVID-19 world. Collaboration between all stakeholders – industry, government and PAGs – will be critical in delivering a holistic solution and pathway to robust infection management. Register
  8. Content Article
    Whole-body bathing or showering with a skin antiseptic to prevent surgical site infections (SSI) is a usual practice before surgery in settings where it is affordable. The aim is to make the skin as clean as possible by removing transient flora and some resident flora. Several organisations have issued recommendations regarding preoperative bathing. The care bundles proposed by the United Kingdom (UK) High impact intervention initiative and Health Protection Scotland recommend bathing with soap prior to surgery. The Royal College of Surgeons of Ireland recommends bathing on the day of surgery or before the procedure with soap . The USA Institute of Healthcare Improvement bundle for hip and knee arthroplasty recommends preoperative bathing with CHG soap. Finally, the UK-based National Institute for Health and Care Excellence (NICE) guidelines recommend bathing to reduce the microbial load, but not necessarily SSI. In addition, NICE states that the use of antiseptics is inconclusive in preventing SSI and that soap should be used. The purpose of this systematic review is to assess the effectiveness of preoperative bathing or showering with antiseptic compared to plain soap and to determine if these agents should be recommended for surgical patients to prevent SSI.
  9. Content Article
    The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest database of patient safety event reports in the US. In addition to over 4.5 million acute care reports, the PA-PSRS database contains more than 396,000 long-term care healthcare-associated infection (HAI) reports. This study in Patient Safety aimed to look at trends in HAIs in long term care using data from the PA-PSRS database. The study found that there was an increase in the total number and rate of infections reported to PA-PSRS in 2022. 
  10. Content Article
    This study in the Journal of Patient Safety and Risk Management aimed to assess the patient safety situation in Ghana across the World Health Organization's (WHO’s) 12 action areas of patient safety. The authors used interviews and observation including a WHO adapted questionnaire across 16 selected hospitals, including two teaching hospitals selected from the northern and southern parts of the Ghana. The key strength identified in the patient safety situational analysis was knowledge and learning in patient safety, while patient safety surveillance was the weakest action area identified. There were also weaknesses in areas such as national patient policy, healthcare associated infections, surgical safety, patient safety partnerships and patient safety funding.
  11. Content Article
    Data published in the New England Journal of Medicine demonstrates that use of CareFusion’s patient preoperative skin preparation ChloraPrep® (2% chlorhexidine gluconate and 70% isopropyl alcohol) reduced total surgical site infections (SSIs) by 41%, from 16.1% to 9.5%, compared to use of povidone-iodine solution, the most commonly used preoperative skin preparation. In this prospective, randomised and well-controlled outcomes trial designed to compare the efficacy of skin antiseptics in reducing the risk of SSIs, ChloraPrep proved superior in clean-contaminated abdominal, urologic, gynecologic and thoracic surgery.  “For nearly a decade, healthcare professionals have relied on the proven efficacy of ChloraPrep,” said Stephen R. Lewis, MD, chief medical officer of CareFusion. “This study is an example of our ongoing commitment to providing clinicians with evidence-based data that clinically differentiates our products in order to help improve patient care and lower costs.”
  12. Content Article
    Remote digital postoperative wound monitoring provides an opportunity to strengthen postoperative community care and minimise the burden of surgical-site infection (SSI). This study aimed to pilot a remote digital postoperative wound monitoring service and evaluate the readiness for implementation in routine clinical practice. It concluded that remote digital postoperative wound monitoring successfully demonstrated readiness for implementation with regards to the technology, usability, and healthcare process improvement.
  13. Content Article
    Central line–associated bloodstream infections (CLABSI) account for many harms suffered in healthcare and are associated with increased costs and disease burden. Central line rounds, like medical rounds, are a multidisciplinary bedside assessment strategy for all active central lines on a unit. The project team designed a HIPAA-protected, text-based process for assessing central lines for risk factors contributing to infection. Staff initiated a consultation via a virtual platform with an interdisciplinary team composed of oncology and infectious disease experts. The virtual discussion included recommendations for a line-related plan of care.
  14. News Article
    Antimicrobial resistance poses a significant threat to humanity, health leaders have warned, as a study reveals it has become a leading cause of death worldwide and is killing about 3,500 people every day. More than 1.2 million – and potentially millions more – died in 2019 as a direct result of antibiotic-resistant bacterial infections, according to the most comprehensive estimate to date of the global impact of antimicrobial resistance (AMR). The stark analysis covering more than 200 countries and territories was published in the Lancet. It says AMR is killing more people than HIV/Aids or malaria. Many hundreds of thousands of deaths are occurring due to common, previously treatable infections, the study says, because bacteria that cause them have become resistant to treatment. “These new data reveal the true scale of antimicrobial resistance worldwide, and are a clear signal that we must act now to combat the threat,” said the report’s co-author Prof Chris Murray, of the Institute for Health Metrics and Evaluation at the University of Washington. “We need to leverage this data to course-correct action and drive innovation if we want to stay ahead in the race against antimicrobial resistance.” Read full story Source: The Guardian, 20 January 2022
  15. News Article
    The NHS must apply Covid infection prevention and control measures more robustly if it is to avoid a steep rise in infections within healthcare settings, a senior doctor at NHS England has said. The warning came from NHS England national clinical director for antimicrobial resistance and infection prevention and control Mark Wilcox during a webinar for NHS leaders. He said that the effectiveness of the vaccination programme had led “understandably” to the NHS being more relaxed when it came to Covid IPC. However, he warned that “the effectiveness of the vaccines has diminished substantially with respect to two doses” because of the omicron variant, and that “if we carry on with the level of IPC that we have been lulled into then we will see very significant problems with nosocomial infection”. Read full story (paywalled) Source: HSJ, 14 December 2021
  16. News Article
    Advice on how new mothers with sepsis should be treated is to change after two women died of a herpes infection. The Royal College of Obstetricians and Gynaecologists says viral sources of infections should be considered and appropriate treatment offered. This comes after the BBC revealed one surgeon might have infected the mothers while performing Caesareans on them. The East Kent Hospitals Trust said it had not been possible to identify the source of either infection. Kimberley Sampson, 29, and Samantha Mulcahy, 32, died of an infection caused by the herpes virus 44 days apart in 2018, shortly after giving birth by Caesarean section. Their families were told there was no link between the deaths but BBC News revealed on Monday that both operations had been carried out by the same surgeon. Documents we uncovered showed that the trust had been told two weeks after the second death that "it does look like surgical contamination". Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, which set standards in maternity care, said routine investigation and management of maternal sepsis "should always consider viral sources of infection, and appropriate changes should be instituted to support earlier diagnosis and treatment". Medics treating Ms Sampson and Mrs Mulcahy assumed they were suffering from a bacterial infection and didn't prescribe the anti-viral medication that may had saved their lives. The Royal College said the two deaths should be "fully investigated" as "surgical infection appears to be a significant possibility". But BBC News has learned that the East Kent Hospitals Trust, which treated both women, never told the coroner's office that the same surgeon had carried out both operations or that an investigation they had ordered had suggested the virus strains the two women had died from appeared to be "epidemiologically linked". Read full story Source: BBC News, 23 November 2021
  17. News Article
    The widow of a top Scottish government official, who died after contracting Covid, believes the full details of his illness were concealed to protect the reputation of a troubled hospital. Andrew Slorance, Scottish government's head of response and communication unit, in charge of its handling of the Covid pandemic, went into Glasgow's Queen Elizabeth University Hospital for cancer treatment a year ago. His wife Louise believes he caught Covid there as well as another life-threatening infection. Andrew went in to the £850m flagship Queen Elizabeth University Hospital (QUEH) at the end of October 2020 for a stem cell transplant and chemotherapy as part of treatment for Mantle Cell Lymphoma (MCL). He died nearly six weeks into his stay, with the cause of his death listed as Covid pneumonia. But after requesting a copy of his medical notes, Mrs Slorance discovered her husband had also been treated for an infection caused by a fungus called aspergillus, which had not been discussed with either of them during his hospital stay. The infection is common in the environment but can be extremely dangerous for people with weak immune systems. Mrs Slorance questions whether it may have played a part in her husband's death, and if so, why she was not told? She told the BBC: "I think somebody and probably a number of people have made an active decision not to inform his family of that infection, either during his admission or post-death." Mrs Slorance believes that officials wanted to protect the hospital, which is already the subject of a public inquiry, and its reputation, "no matter what the cost". Mrs Slorance says a full investigation should take place into incidences of aspergillus at the hospital campus. In response, NHS Greater Glasgow and Clyde said: "We are sorry that the family are unhappy with aspects of Mr Slorance's treatment, details of which were discussed with the family at the time. "While we cannot comment on individual patients, we do not recognise the claims being made. We are confident that the appropriate care was provided. There has been a clinical review of this case and we would like to reassure the family that we have been open and honest and there has been no attempt to conceal any information from them." Read full story Source: BBC News, 18 November 2021
  18. News Article
    Some acute trusts have failed to report large numbers of hospital-acquired covid infections as patient safety incidents, despite NHS England describing this as ‘fundamental’. HSJ examined the numbers of “infection control” patient safety incidents reported to the national reporting and learning system in 2020-21, and compared this to separate NHS England data on covid infections most likely to have been acquired in hospital. The number of incidents reported to the NRLS in the 12-month period should in theory be higher, as it covers all types of hospital-acquired infections, while the NHSE data only covered covid infections in the last seven months of the year. This appears to hold true nationally, with almost 59,000 incidents reported to the NRLS, compared to around 36,000 likely hospital-acquired covid infections suggested by the NHSE data. But for around a third of trusts, the incident numbers reported to the NRLS were smaller, with some appearing to report very low numbers. Helen Hughes, chief executive of patient safety charity Patient Safety Learning, said: “The scale of the under-reporting set out in these findings is particularly concerning.” “As this data informs assessment of performance at both organisational and national levels, it is possible that this could create a false assurance about the extent of harm in this period,” Ms Hughes said. “Where organisations are now retrospectively completing serious incident reports, there are obvious questions as to whether key insights will have been lost as memories of incidents fade over time and their causes.” “However, they rely on the capacity and commitment of staff behind them. The pandemic has placed an enormous strain on the health service and we have heard from staff the time constraints this has put on them to report patient safety incidents,” she added. Read full story (paywalled) Source: HSJ, 15 October 2021
  19. News Article
    The Becker's Clinical Leadership & Infection Control editorial team chose the top 10 patient safety issues for healthcare leaders to prioritise in 2021, presented below in no particular order, based on news, study findings and trends reported in the past year. COVID-19 Healthcare staffing shortages Missed and delayed diagnoses Drug and medicine supply shortages Low vaccination coverage and disease resurgance Clinical burnout Health equity Healthcare-associated infections Surgical mistakes Standardising safety efforts. Read full story Source: Becker's Healthcare, 30 December 2020
  20. News Article
    A hospital serving the prime minister’s constituency has been issued a warning notice by inspectors over poor infection control, including staff having to share two small toilet cubicles for changing. The Care Quality Commission (CQC) announced it has issued the notice to The Hillingdon Hospitals FT today following an unannounced inspection in September. It comes after the watchdog placed urgent conditions on the provider following a coronavirus outbreak among staff at Hillingdon Hospital in August. At least 70 members of staff had to isolate, some of whom had tested positive for covid. The watchdog said it found there had been improvements, but that “further work is needed”. The CQC’s inspection report, published today, said there were no staff changing rooms available for people to change in and out of their scrubs, and that they were sharing two small toilet cubicles at the start and end of shifts. These were not cleaned with an “enhanced” cleaning schedule, it added, and the lack of separate changing rooms “caused a risk of cross-contamination”. However, senior leaders were aware of the risk and were seeking ways to improve access to changing areas for staff. Read full story (paywalled) Source: HSJ, 4 December 2020
  21. News Article
    Hospital hotspots for COVID-19 have been highlighted in a new report by safety investigators. The report by the Healthcare Safety Investigation Branch (HSIB) makes a series of observations to help the health service reduce the spread of coronavirus in healthcare settings. Hospital hotspots for COVID-19 included the central nurses’ stations and areas where computers and medical notes were shared, the HSIB found. The investigation was initiated after a Sage report in May which found that 20% of hospital patients were reporting symptoms of Covid-19 seven days following admission – suggesting that their infection may have been acquired in hospital. In response to the report, NHS England and NHS Improvement confirmed they would publish nosocomial – another term for hospital acquired infections – transmission rates from trusts, the HSIB said. Read full story Source: Express and Star, 28 October 2020
  22. News Article
    Minority ethnic people in UK were ‘overexposed, under protected, stigmatised and overlooked’, new review finds. Structural racism led to the disproportionate impact of the coronavirus pandemic on black, Asian and minority ethnic (BAME) communities, a review by Doreen Lawrence has concluded. The report, commissioned by Labour, contradicts the government’s adviser on ethnicity, Dr Raghib Ali, who last week dismissed claims that inequalities within government, health, employment and the education system help to explain why COVID-19 killed disproportionately more people from minority ethnic communities. Lady Lawrence’s review found BAME people are over-represented in public-facing industries where they cannot work from home, are more likely to live in overcrowded housing and have been put at risk by the government’s alleged failure to facilitate Covid-secure workplaces. She demanded that the government set out an urgent winter plan to tackle the disproportionate impact of Covid on BAME people and ensure comprehensive ethnicity data is collected across the NHS and social care. The report, entitled An Avoidable Crisis, also criticises politicians for demonising minorities, such as when Donald Trump used the phrase “the Chinese virus”. The report, which is based on submissions and conversations over Zoom featuring “heart-wrenching stories” as well as quantitative data, issued the following 20 recommendations: Set out an urgent plan for tackling the disproportionate impact of Covid on ethnic minorities Implement a national strategy to tackle health inequalities Suspend ‘no recourse to public funds’ during Covid Conduct a review of the impact of NRPF on public health and health inequalities Ensure Covid-19 cases from the workplace are properly recorded Strengthen Covid-19 risk assessments Improve access to PPE in all high-risk workplaces Give targeted support to people who are struggling to self-isolate Ensure protection and an end to discrimination for renters Raise the local housing allowance and address the root causes of homelessness Urgently conduct equality impact assessments on the government’s Covid support schemes Plan to prevent the stigmatisation of communities during Covid-19 Urgently legislate to tackle online harms Collect and publish better ethnicity data Implement a race equality strategy Ensure all policies and programmes help tackle structural inequality Introduce mandatory ethnicity pay gap reporting End the ‘hostile environment’ Reform the curriculum Take action to close the attainment gap Read full story Source: The Guardian, 28 October 2020
  23. News Article
    An investigation into the outbreak of a bacterial infection that killed 15 people has found there were several “missed opportunities” in their care. Mid Essex Clinical Commissioning Group has released the outcome of a 10-month investigation into a Strep A outbreak in 2019, which killed 15 people and affected a further 24. The final report was critical of Provide, a community interest company based in Colchester, as well as the former Mid Essex Hospital Services Trust (now part of Mid and South Essex Foundation Trust). It said: “This investigation has identified that in some cases there were missed opportunities where treatment should have been more proactive, holistic and timely. These do not definitively indicate that their outcomes would have been different.” Investigators found that 13 of the 15 people that died had received poor wound care from Provide CIC. They reported that inappropriate wound dressings were used and record keeping was so poor that deterioration of wounds was not recognised. Even wounds that had not improved over 22 days were not escalated to senior team members for help or referred to the tissue viability service for specialist advice, with investigators told this was often due to concerns over team capacity. The report, commissioned by the CCG and conducted by consultancy firm Facere Melius, said: “[Some] individuals became increasingly unwell over a period of time in the community, yet their deterioration either went unnoticed or was not acted upon promptly. Sometimes their condition had become so serious that they were very ill before acute medical intervention was sought”. Other findings included delays in the community in the taking of wound swabs to determine if the wound was infected and by which bacteria. It said in one case nine days elapsed before the requested swab took place. Even after Public Health England asked for all wounds to be swabbed following the initial outbreak, this was only conducted on a single patient. In other cases there were delays in patients being given antibiotics and this “could have had an adverse impact on the treatment for infection”. It also found that sepsis guidelines were not accurately followed, wounds were not uncovered for inspection in A&E, and some patients were given penicillin-based antibiotics despite penicillin allergies being listed in their health records. Read full story (paywalled) Source: HSJ, 17 September 2020
  24. News Article
    The first new hospital cleaning standards for 14 years have been outlined by regulators, including confirmation of new food hygiene-style star ratings. Wards and theatres will be given ratings from one to five stars – based on audits which score the cleanliness of areas against safe standards – and these ratings will be made visible to patients. The plans for the new star ratings, which are expected to be easier for patients to understand than the current cleanliness percentage scores, were first revealed by HSJ in 2019. The ratings are also designed to encourage a more collaborative approach, by reflecting the cleanliness score for whole areas, as opposed to the performance of individual parties responsible for cleaning certain elements. Areas rated one to three stars would require improvement plans and be automatically placed under review, with “immediate action” being required in one-star rated areas. Read full story (paywalled) Source: HSJ, 6 May 2021
  25. News Article
    An infection "probably" linked to Glasgow's children's hospital was the "primary cause of death" of a young cancer patient, the BBC has learned. Infections from contaminated water at the hospital were also found to have been an "important contributory factor" in another child's death. A review looked into the cases of 84 children who developed infections while undergoing treatment at the hospital. It found that a third of infections "probably" originated in the hospital and the rest were "possibly" acquired there. The authors of the "case note review", which should be published next week, said they recognised that some families would be disappointed that they could not have "greater certainty" about the links between their child's infection and the hospital environment. They said this was down to the limits of a retrospective review but also criticised the shortcomings in the data provided by the health board. Read full story Source: BBC News, 20 March 2021
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