National news
The Care Quality Commission has published its second annual report into the state of health and adult social care in England.
Action required: To be read by all healthcare professionals and managers.
NPSA releases Organisation Patient Safety Incident reporting data (England)
The National Patient Safety Agency (NPSA) has published the latest set of Organisation Patient Safety Incident data. The number of patient safety incidents reported between 1 April and 30 September 2010 has increased 4% on the same period in 2009.
Action required: To be read by all risk managers.
Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants
The NPSA has issued guidance to reduce the harm caused by misplaced nasogastric feeding tubes, which have caused 21 deaths and 79 cases of harm since 2005. pH testing remains the first line test that a nasogastric feeding tube is inserted correctly. An x-ray must only be used as a second line check. However, if an x-ray is to be used, the alert supports safe x-ray interpretation.
Action required: To be read by all healthcare professionals and managers.
Passport to safer use of insulin
The NPSA is asking NHS organisations to give all adult patients on insulin therapy an Insulin Passport to help improve accurate identification of their current insulin products. This Patient Safety Alert follows a review of 16,600 patient safety incidents involving insulin over a six year period between 1 November 2003 and 1 November 2009.
Action required: To be read by all healthcare professionals and managers.
Major complications of airway management in the UK
A major UK study on complications of anaesthesia has shown that obese patients are twice as likely to develop serious airway problems during a general anaesthetic than non-obese patients. The study also shows that the use of a simple breathing monitor, called a capnograph, could significantly reduce deaths and brain damage from such problems in intensive care units (ICUs).
Action required: To be read by all anaesthetists.
New guidance to stop people dying from acute gastric bleeding
The Royal College of Physicians has published new guidance to help prevent unnecessary deaths from acute gastrointestinal bleeding with a toolkit that will improve the diagnosis and management of patients with acute gastric bleeding, particularly for those presenting at night and at the weekend.
Action required: To be read by all clinicians and managers.
Cardiac surgeons call for greater transparency and access to information for NHS patients
A new report from the Society for Cardiothoracic Surgery [SCTS], Maintaining patients’ trust: modern medical professionalism says that data collection improves patient care: Access to reliable information protects and informs patients by explaining variance and preventing poor practice. Public reporting at hospital and individual surgeon level has resulted in a 50% improvement in risk adjusted mortality rates for cardiac.
Action required: To be read by all cardiology clinicians and managers
This bulletin is brought to you by Library and Knowledge Services. It aims to keep you up-to-date with infection control issues. At the beginning of each month, a librarian will update the bulletin with relevant information published in the preceding month. If there are areas you think we also need to cover, please let us know.
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