Latest reports from the Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO)

The reports set out the work of the Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO) during 2014 to 2017 and can be accessed at https://www.gov.uk/government/publications/sabto-annual-reports

Five safe, sustainable and productive staffing improvement resources

NHS Improvement has published five safe, sustainable and productive staffing improvement resources in the areas of maternity services, adult inpatients in acute care, district nursing services, learning disability services and mental health.

Temporary suspension of undetected oesophageal intubation category of Never Event

The new ‘undetected oesophageal intubation’ category of Never Event has been temporarily suspended from the 2018 Never Events list while a query about it is being resolved.

You will not need to report this category of incident as a Never Event until the suspension has been lifted. We will let you know when this category of Never Event has been reinstated.

5 years on: responses to Francis: changes in board leadership and governance in acute hospitals in England since 2013

This report, written by the Health Services Management Centre, University of Birmingham in partnership with the University of Manchester and the Nuffield Trust, reveals that hospital boards report that they are placing a high priority on care quality and safety, and many invested significantly in nurse and medical staffing in the wake of the Francis Report. However, some hospital boards reported feeling that quality assurance as a pressure, as the demands of multiple external regulators was reported to sometimes feel burdensome, threatening to distract from a focus on the actual work of service improvements.

SaBTO microbiological safety guidelines 2017

Guidance from the Department of Health and Social Care on the microbiological safety of human organs, tissues and cells used in transplantation.

Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders

Patient safety alert from NHS Improvement on the risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders.

JLA seeks views on safe care for adults with complex health needs

The James Lind Alliance (JLA) is seeking help with their research into the safe care for adults with complex health needs.

The JLA and the NIHR Imperial Patient Safety Translational Research Centre are calling on healthcare professionals, including members and fellows of the College, to submit questions they would like answered on the subject.

Submitted questions will then be prioritised through a second survey in order to determine the top ten priority areas for the research.

Framework for maximising the use of care homes and use of therapy-led units for patients medically fit for discharge

This best practice framework from NHS England aims to address two models and the implementation approach that needs to be taken by sustainability and transformation partnerships (STPs) and their provider organisations with ensuing threats to patient safety, during the winter months.

Gadolinium contrast agents and risk of tissue accumulation—removal of Omniscan and intravenous Magnevist from February; restrictions to use of other linear agents

From 1 February 2018, intravenous forms of gadodiamide (Omniscan) and gadopentetic acid (also known as gadopentetate dimeglumine; intravenous Magnevist) linear contrast agents for MRI will no longer be licenced and any remaining stock will be recalled from the market. The authorised indication of the linear agents gadobenic acid (also known as gadobenate dimeglumine; MultiHance) and gadoxetic acid (Primovist) will be limited to delayed phase liver imaging only.

RCOphth Safety Announcement: BSS and Open Systems for Injectable Medicines

Following reported errors of drug misidentification in other specialties causing serious harm, when an injectable medication was decanted into an ‘open system’, e.g. a gallipot, before administration, NHS Improvement has expressed concerns to RCOphth about the widespread practice during cataract surgery of decanting BSS (balanced salt solution) from the infusion bag into a gallipot at the start of the procedure which may then be drawn up and used to re-inflate the eye later in the operation. In addition, concern was raised that BSS kept in a gallipot might pose a risk of potential bacterial contamination.

In response, the College has replied that given the short duration that BSS typically remains in a sterile gallipot during cataract surgery, it does not consider that this practice poses a sterility issue. However there is a potential risk for drug misidentification although no other drug would commonly be placed into a gallipot during cataract surgery. RCOphth has pointed out that BSS is not currently available as a pre-filled syringe and that preparing and labelling of several syringes of BSS at the beginning of each case would be both impractical and potentially wasteful.

New ways to avoid wrong IOLs

The Royal College of Ophthalmologists is aware that never events relating to the insertion of wrong intraocular lenses (IOLs) is an ongoing problem and that members continue to have concerns about how best to avoid such incidents, and about how to ensure there is no unhelpful blame or punitive measures which lead to financial penalties or inhibit reporting and learning.

Response to the consultation on the draft Ionising Radiation (Medical Exposure) Regulations 2018

This document summarises responses to a DH consultation on transposing EU directives on protection against the dangers arising from medical exposure to radiation.

An uncommon approach: four organisations selected to replicate health and social care interventions

Four organisations have each been awarded £145,000 by the Health Foundation to replicate successful health and care interventions using social franchising and licensing techniques. Social franchising and licensing are methods to replicate and scale interventions that have not yet been used widely in health care in the UK.

The projects are:

Scaling and replicating IRIS through social franchising

Lead organisation: IRISi

IRIS is a successful general practice-based training, support and referral programme that improves the identification and support offered to people with experience of domestic violence and abuse (DVA). One in four women and one in six men will experience DVA during their lifetime, with DVA against women being more frequent and more severe, with long-lasting effects that also have an impact on children. IRIS will be replicated through social franchising so that the programme can be implemented more widely, and more people can be supported. IRISi, a social enterprise set up to house the programme, will support other sites to engage commissioners, and recruit and train staff.

Replicating Pathway’s homeless health hospital team model to towns and cities experiencing significant homelessness

Lead organisation: Pathway

Homeless patients attend emergency departments four times more often than the general population, are admitted eight times more often and stay three times as long. Ten hospitals have implemented Pathway’s integrated care model ensuring that homeless patients admitted to hospital have access to the health care they need and support to recover. Pathway will use social franchising or licensing to replicate the model in places with significant homeless populations that would benefit from adopting it.

Scale up, replication and licensing of the PINCER intervention

Lead organisation: The University of Nottingham

In a recent study, prescribing errors were identified in 5% of prescription items, with one in 550 items containing a severe (potentially life threatening) error. This equates to around 1.8 million serious prescribing errors in English general practices each year. PINCER is a successful pharmacist-led information technology intervention for reducing common medication errors in general practice prescribing, and has been incorporated into national guidelines to support medicines optimisation. PINCER will be replicated in GP surgeries across the country; helping them to protect patients at risk of errors, and reduce medication-related hospital admissions and deaths.

Developing a licensed, social franchising model for regional hubs to roll out effective local multi-professional maternity training

Lead organisation: PROMPT Maternity Foundation

The PRactical Obstetric Multi-Professional Training (PROMPT) programme has been associated with a significant reduction in the number of babies with a low oxygen level at birth and also babies born with a permanent nerve injury following difficulties with their shoulders. Through social franchising and using a regional hub system, it is hoped that this improved implementation model will ensure that PROMPT training may be associated with the same improvements in outcomes across the country.

The new projects are currently subject to contracts being finalised.

Survey of Dermatologists and Venereologists Shows Varying Approach to Penile Biopsies

J Clin Aesthet Dermatol. 2017;10(10):26–27

Objective. To determine frequency of use and safety of epinephrine containing local anesthesia among dermatologists in the United Kingdom and venereologists undertaking penile biopsy.

Conclusion. Use of epinephrine-containing local anesthesia is common among physicians in the United Kingdom undertaking penile biopsies. Despite this, no episodes of necrosis were observed. While further investigation is still required, it is likely that use of epinephrine-containing local anesthesia is safe for local penile injection.

UHCW Research: Aaron Wernham and Tang Ngee Shim

Winter service pressures and the role of anaesthetists in training

During last winter some anaesthetists in training were asked to work outside of their usual scope of practice due to unprecedented demands on clinical services. The AAGBI communicated its concerns to Health Education England and issued guidance. 

As winter approaches again, it may be timely for all anaesthetists to note the guidance which remains relevant.

Do nice guys finish last?

Emerg Med J. 2017 Dec;34(12):A879-A880. doi: 10.1136/emermed-2017-207308.30.

Emergency medicine is widely recognised as an intense specialty. Interruptions are known to derail thoughts, increasing cognitive load and result in longer periods before deep thought is re-established. Although approachability and warmth are regarded as important factors in clinicians we wondered what impact these characteristics had on the number of interruptions.

UHCW Research: Turner C and Turner J

Eyes Right!

New RCN guidance, Eyes Right!, helping non-ophthalmic health care professionals deliver quality care safely.

Safe, sustainable and productive staffing in urgent and emergency care

Draft resource from NHS Improvement to help standardise safe, sustainable and productive staffing decisions in urgent and emergency care.

Safe, sustainable and productive staffing for neonatal care and children and young people's services

Draft resources from NHS Improvement to help standardise safe, sustainable and productive staffing decisions in neonatal care and children and young people's services.

Safe transfusion practice: use a bedside checklist

Serious Hazards of Transfusion (SHOT), has repeatedly identified that patients are harmed, and some die, as a result of being given the incorrect type of blood.

SHOT therefore recommends a structured process with a bedside checklist; this alert provides information against which organisations should assess their bedside systems.