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EMBARGOED until 00.01 hrs Monday 14 March 2005


Unveiling the findings of its fourth special report into hospital acquired infection since 2000, the Patients Association today called for the adoption across the NHS of modern electronic ‘data capture’ systems to allow individual medical devices to be tracked as they move around hospitals and external cleansing facilities. Many Trusts still use paper based systems to record instrument usage, a potential threat to patient safety, according to new research published today by the Patients Association. The survey looked in particular at whether the back-up systems were in place to quickly withdraw problem medical devices, such as when a high cross-infection risk is identified from a previous patient.

“The findings of our latest survey on hospital acquired infection indicate that patient safety is not as good as it could be. Among the hospital professionals we surveyed, it would seem very clear that the current government guidance mandating the tracing of sets of instruments in trays is insufficient and doesn’t have professional support. I hope Ministers will take note and act to ensure improved tracking systems, tagging each and every instrument, are mandated across the NHS,” said Simon Williams, Director of Policy at the Patients Association.

97% of hospital staff surveyed by the Patients Association said that the new generation of off-site sterile service decontamination “super centres” due to be built in the next few years need to have tracking and tracing systems for individual medical devices in order to guarantee effective patient safety. 78% of respondents said that better tracking systems would improve patient safety within current hospital facilities as a whole.

Explaining the findings, Simon Williams said: “Current Department of Health guidance only requires the tracking of trays of instruments, not individual items. This limits the effectiveness of attempts to trace instruments which have been used on a patient later found to have a high risk infection. Too many Trusts seem to be resisting investing in the latest systems because department of health guidance doesn’t call for full instrument tracking systems. This must be impacting on patient safety.”

The new 2004/05 Patients Association survey also reveals on-going fears among health professionals about the overall cleanliness of medical devices. This repeats the findings of the previous Patients Association surveys in 2000, 2001 and 2002. Almost a quarter of front line hospital professionals surveyed by the Patients Association at the end of 2004 reported frequent cleanliness problems with medical devices after the decontamination process had taken place. Around one-in-ten respondents said up to 5% of devices they saw had problems after cleaning. “In a large hospital that’s many hundreds of devices a year,” said Simon Williams. The Patients Association is worried by such high levels of problems with cleaning when millions of pounds has been spent on new medical device decontamination equipment since 2001.

Simon Williams, Director of Policy for the Patients Association, said:

“This survey overwhelmingly shows that there is a strong need to track individual surgical instruments to protect patient safety using modern IT systems. With the development of the new network of super centres, the Department of Health needs to update its guidance to hospitals on the requirements for tracking and tracing systems. With the technology now available to individually code most medical devices the reasons for resisting this significant patient safety step must be few. The continuing concerns about overall instrument cleanliness we report today just add to the need for action.”


Notes to editors:

1. The findings of the report will be presented to parliamentarians, civil servants and health experts at a seminar near Westminster (King George V Room, Marriott County Hall) on Monday 14 March at 4 pm. Journalists are welcome to attend.

The survey of front-line theatre, infection control and sterile services staff was conducted in November and December 2004. Among the key findings:

- 78% said that better hospital tracking systems would improve patient safety.

- 97% agreed that the new generation of off-site sterile services Super Centres would need tracking systems to log individual items to guarantee effective patient safety.

- Less than half (44%) of those that responded to the survey said that they actually tracked individual surgical instruments, as opposed to tray sets, in sterile services.

- Just over a third of respondents (39%) reported that it was impossible to track back and locate a single individual surgical instrument.

- The use of paper based tracking systems varied by department – around one-third in sterile services, two-thirds for theatre and endoscopy.

2. Copies of the reports are available on request and at

3. Simon Williams is available for interview – please phone +44 7730 898 165.

4. The latest PA Hospital Acquired Infection report, “Infection Control and the Management of Medical Devices” is the result of a collaboration between the Patients Association, the Institute of Decontamination Sciences (IDSc), the Infection Control Nurses Association (ICNA) and the National Association of Theatre Nurses (NATN). The three professional groups (IDSc, ICNA and NATN) sent out 200 questionnaires each to a random sample of their members. The questionnaires were sent out and returned during November and December 2004. The response rate was 21%.

5. The previous Patients Association reports are: “Hospital Acquired Infection and the Reuse of Medical Devices” (June 2000). This attracted major publicity and led to significant new policy and investment by the Department of Health. The 2001 report was entitled “The Decontamination of Surgical Instruments: A Survey of Hospital Staff in the UK” and was designed to probe for progress with the implementation of Health Service Circular 2000/32, issued partly in response to the concerns exposed in our first report in 2000. The 2002 report was based on a survey of the new strategic health authorities to assess how much the new SHAs would be following the decontamination and medical device issue under the new localism agenda under Shifting the Balance.

6. The 2004/05 survey work was supported by GS1 UK (formerly e.centre), a not-for-profit membership based business organisation. GS1 UK is the UK authority on best practice and standards development for multi-sector supply-chains. Its standards for coding can be seen on almost all retail products and are most commonly portrayed in bar codes which can be scanned to track and trace goods and services as they move throughout a supply chain.

7. These issues, and others, will be discussed at the Patients Association Clean Hospitals Summit on 14/15 April 2005 in central London. See for more details.

8. Media enquires only to:

Nick Sutcliffe 020 7526 3622 or 07730 898 165

Jonathan Simpson 020 7526 3621 or 07968 537 321

9. Public enquiries to:

PA administration office: 020 8423 9111

PA Helpline: 0845 6084455

This press release was distributed by ResponseSource Press Release Wire on behalf of APCO UK in the following categories: Health, for more information visit