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Bulletin references October 2023

A full list of references for the October Bulletin is available here.

You can download a copy of the October 2023 Bulletin from our Bulletin pages.

Pathology challenges and the way forward

How can we reduce errors and make transfusion practice safer?

  1. International Society of Blood Transfusion. Haemovigilance. Available at: www.isbtweb.org/isbt-working-parties/haemovigilance.htm
  2. Bolton-Maggs PHB, Cohen H. Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety. Br J Haematol 2013;163:303–314. 
  3. Bolton-Maggs PHB and Watt A. Transfusion errors – can they be eliminated? Br J Haematol 2020;189:9–20.
  4. Williamson LM, Lowe S, Love E, Cohen H, Soldan K, McClelland DBL et al. SHOT Annual Report 1996/1997. Manchester, UK: SHOT, 1998. Available at: www.shotuk.org/wp-content/uploads/myimages/2010/03/SHOT-Report-96-97.pdf 
  5. Narayan S, Baker P, Bellamy M, Bentley A, Birchall J, Bolton-Maggs PHB et al on behalf of the SHOT Steering Group. The 2021 Annual SHOT Report. Manchester, UK: SHOT, 2022. Available at: www.shotuk.org/shot-reports/report-summary-and-supplement-2021/ 
  6. UK Government. Blood Safety and Quality (Amendment) (No.2) Regulations 2005 No.2898. 2005. Available at: www.legislation.gov.uk/uksi/2005/2898/contents/made
  7. NHS National Patient Safety Agency. Safer Practice Notice: Right Patient, Right Blood. 2006. Available at: webarchive.nationalarchives.gov.uk/ukgwa/20180501161059/http:/www.nrls.npsa.nhs.uk/resources/collections/right-patient-right-blood/   
  8. Davies SC. Safe Transfusion Practice: Use a Bedside Checklist. London, UK: Medicines and Healthcare products Regulatory Agency, 2017. Available at: www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=10266
  9. SHOT. Cumulative Data from SHOT Relating to TACO. Available at: www.shotuk.org/resources/current-resources/data-drawers/transfusion-associated-circulatory-overload-taco-data-drawer/#:~:text=Transfusion-Associated%20Circulatory%20Overload%20%28TACO%29%20Cumulative%20Data%20Definition%3A%20TACO,not%20explained
  10. SHOT. Preventing Transfusion Delays in Bleeding and Critically Anaemic Patients. London, UK: Medicines and Healthcare products Regulatory Agency, 2022. Available at: www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103190 
  11. Bolton-Maggs PHB, Bellamy M, Watt A, Poles D, Mistry H, Carter-Graham S et al on behalf of the SHOT Steering Group. The 2017 Annual SHOT Report. Manchester, UK: SHOT, 2018. Available at: www.shotuk.org/wp-content/uploads/myimages/SHOT-Report-2017-WEB-Final-v4-25-9-18.pdf 
  12. Murphy MF, Addison J, Poles D, Dhiman P, Bolton-Maggs PHB. Electronic identification systems reduce the number of wrong components transfused. Transfusion 2019;59:3601–3607.
  13. Staples S, Staves J, Davies J, Polley N, Boyd JS, Lukas M et al. Electronic remote blood issue supports efficient and timely supply of blood and cost reduction: evidence from five hospitals at different stages of implementation. Transfusion 2019;59:1683–1691.
  14. Braithwaite J, Wears RL, Hollnagel E. Resilient health care: turning patient safety on its head. Int J Qual Health Care 2015;27:418–420.
  15. Narayan S, Baker P, Bellamy M, Bentley A, Birchall J, Bolton-Maggs PHB et al on behalf of the SHOT Steering Group. The 2022 Annual SHOT Report. Manchester, UK, SHOT, 2023. Available at: www.shotuk.org/shot-reports/report-summary-and-supplement-2022/ 
  16. World Health Organisation. Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. 2021. Available at: www.who.int/publications/i/item/9789240032705
  17. Holden RJ, Carayon P. SEIPS 101 and seven simple SEIPS tools. BMJ Qual Saf 2021;30:901–910.

The impact of workforce shortages on tackling antimicrobial resistance and healthcare-associated infections

  1. United Kingdom Strategic Health Agency. Three Year Strategic Plan 2023-2026. 2023. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1173959/UKHSA_3_year_strategy.pdf
  2. Lawrence S, Aggarwal D, Davies A, Partridge D, Ratnaraja N, Llewelyn MJ. The state of hospital infection services in the UK: National Workforce Survey 2021. Clin Infect Pract 2022;15:100151.
  3. The Royal College of Pathologists. 2023 Infection Sciences Workforce. London, UK: The Royal College of Pathologists, 2023. Available at: www.rcpath.org/profession/workforce-planning/our-workforce-research/the-infection-sciences-workforce.html 
  4. Llewelyn MJ, Price N, Ratnaraja N, Atkins B, Partridge D, Jeffery K. Where now for infection services in the NHS? How lessons from the pandemic should drive long-overdue integration of microbiology and infectious diseases. Clinical Medicine 2022;22:586–589.
  5. United Kingdom Strategic Health Agency. Start Smart then Focus: Antimicrobial Stewardship Toolkit for Inpatient Care Settings. 2023. Available at: www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus/start-smart-then-focus-antimicrobial-stewardship-toolkit-for-inpatient-care-settings
  6. Department of Health and Social Care. Health and Social Care Act 2008: Code of Practice on the Prevention and Control of Infections. 2022. Available at: www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-of-practice-on-the-prevention-and-control-of-infections-and-related-guidance 
  7. Timbrook TT, Prinzi AM, Spivak ES. Diagnostic and antimicrobial stewardship workforce challenges: A crisis in combating antimicrobial resistance. Antimicrob Steward Healthc Epidemiol 2023;3:e60.
  8. Van Spronsen AD, Zychla L, Villatoro V, Yuan Y, Turley E, Ohinmaa A. Engaging laboratory staff in stewardship: barriers experienced by medical laboratory technologists in Canada. J Appl Lab Med 2022;7:480–494.
  9. Vaughn VM, Dunn GE, Horowitz JK, McLaughlin ES, Gandhi TN. Duties, resources and burnout of antibiotic stewards during the coronavirus 2019 (COVID-19) pandemic. Antimicrob Steward Healthc Epidemiol 2021;1;e39.
  10. United Kingdom Strategic Health Agency. National Statistics: Quarterly Epidemiological Commentary: Mandatory Gram-negative Bacteraemia, MRSA, MSSA and C. Difficile Infections. 2023. Available at: www.gov.uk/government/statistics/mrsa-mssa-gram-negative-bacteraemia-and-cdi-quarterly-report/quarterly-epidemiological-commentary-mandatory-gram-negative-bacteraemia-mrsa-mssa-and-c-difficile-infections-data-up-to-april-to-june-2022 
  11. National Institute for Health and Care Excellence. COVID-19 Rapid Guideline: Antibiotics for Pneumonia in Adults in Hospital. NICE Guideline [NG173]. 2020. Available at: www.nice.org.uk/guidance/ng173  
  12. Andrews A, Budd EL, Hendrick A, Ashiru-Oredope D, Beech E, Hopkins S et al. Surveillance of antibacterial usage during the COVID-19 pandemic in England, 2020. Antibiotics (Basel) 2021;10:841.
  13. Ratnaraja N, Davies AP, Atkins BL, Dhillon R, Mahida N, Moses S et al. Best practice standards for the delivery of NHS infection services in the United Kingdom. Clin Infect Pract 2021;12:100095.

Fetal RhD screening of maternal blood to support targeted Anti D prophylaxis – the story so far 

  1. National Institute for Health and Care Excellence. High Throughput Non-invasive Prenatal Testing for Fetal RHD Genotype. London, UK: NICE, 2016. Available at: www.nice.org.uk/guidance/dg25             
  2. National Institute for Health and Care Excellence. Review of DG25: High-Throughput Non-invasive Prenatal Testing for Fetal RHD Genotype. London, UK: NICE, 2021. Available at: www.nice.org.uk/guidance/dg25/evidence/review-decision-april-2021-pdf-9078748237        
  3. British Society for Haematology. Blood Grouping and Antibody Testing in Pregnancy. London, UK: BSH, 2016. Available at: b-s-h.org.uk/guidelines/guidelines/blood-grouping-and-antibody-testing-in-pregnancy
  4. Soothill P, Finning K, Latham T, Wreford-Bush T, Ford J, Daniels G. Use of cffDNA to avoid administration of anti-D to pregnant women when the fetus is RhD-negative: implementation in the NHS. Br J Obstet Gynae 2015;122:1682–1686.

Who does the College serve? Perspective from an England regional representative

  1. Royal charities and patronages. Available at: www.royal.uk/charities-and-patronages
  2. The Royal College of Pathologists. The Royal Charter, Ordinances and By-laws of The Royal College of Pathologists. Published March 2022. Available at: www.rcpath.org/static/99a656e8-4b77-44dd-a7dc932fe2ddf23c/RCPath-Charter-Ordinances-By-laws-March-2022.pdf
  3. Lilley R. How do we fix the NHS? Ask frontline staff. The Guardian. Published February 2013. Available at: www.theguardian.com/healthcare-network/2013/feb/13/fix-nhs-frontline-staff-roy-lilley 

College news

Transforming our College and pathology practice together

  1. NHS. Treatment: Gender dysphoria. Available at: www.nhs.uk/conditions/gender-dysphoria/treatment/
  2. Herman JL, Flores AR, O’Neill KK. How many adults identify as transgender in the United States? Los Angeles, CA, USA: The Williams Institute, June 2022. Accessed 8 July 2023. Available at: www.williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/
  3. Office for National Statistics. Gender identity, England and Wales. Census 2021. Accessed 8 July 2023. Available at: www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/genderidentity/bulletins/genderidentityenglandandwales/census2021

Sharing our subject

Social disparities in medicine – promoting pathology to high-achieving 6th Form students from lower socioeconomic backgrounds

  1. Social Mobility Foundation. Who you know, not what you know: why is the work of the Social Mobility Foundation so important? 2020. Available at: www.socialmobility.org.uk/wp-content/uploads/2020/06/Social-mobility-information-pack-for-mentors-2020.pdf
  2. Social Mobility Foundation. 2022/23 Impact report. 2023. Available at: www.socialmobility.org.uk/wp-content/uploads/2023/05/Social-Mobility-Foundation-Impact-Report-2022%E2%80%9323.pdf 

Training

The Royal College of Physicians’ Chief Registrar Programme – an insight into senior leadership roles

  1. Future Hospital Commission. Future Hospital: Caring for Medical Patients. A Report from the Future Hospital Commission to the Royal College of Physicians. London, UK: Royal College of Physicians, 2013. Available at: www.rcplondon.ac.uk/projects/outputs/future-hospital-commission
  2. Royal College of Physicians. Chief Registrar Programme: Information for Trainee Doctors. 2021. Available at: www.rcplondon.ac.uk/projects/outputs/chief-registrar-programme-information-trainee-doctors

Working smarter

A cross-department working model supporting an out-of-hours deceased donor human leukocyte antigen typing service

  1. NHS Blood and Transplant. Taking organ transplantation to 2020. Available at: www.odt.nhs.uk/odt-structures-and-standards/key-strategies/archived-strategies/taking-organ-transplantation-to-2020/ 
  2. NHS Blood and Transplant. Organ donation and transplantation 2030: Meeting the need. Available at: www.odt.nhs.uk/odt-structures-and-standards/key-strategies/meeting-the-need-2030/ 
  3. Department for Health. Organs for transplants: A report from the Organ Donation Taskforce. 2008. Available at: www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2020/09/DOH-organ-donation-taskforce-report-2008.pdf    
  4. NHS Blood and Transplant. Donor characterisation review report. 2017. Available at: www.odt.nhs.uk/transplantation/pathology-services/donor-characterisation/
  5. Department for Health and Social Care. Productivity in NHS hospitals. 2015. Available at: www.gov.uk/government/publications/productivity-in-nhs-hospitals

Reworking clinical governance for pathology – a fresh start

  1. Healthcare Improvement Scotland. Learning from Adverse Events Through Reporting and Review: A National Framework for Scotland. 2019. Available at: www.healthcareimprovementscotland.org/our_work/governance_and_assurance/learning_from_adverse_events/national_framework.aspx

People

The William Tong Prize – ultra-sensitive HBV DNA detection and risk prediction of occult hepatitis B virus infection in blood donors in England

  1. Candotti D, Assennato SM, Laperche S, Allain JP, Levicnik-Stezinar S. Multiple HBV transfusion transmissions from undetected occult infections: revising the minimal infectious dose. Gut 2019;68:313–321.