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National Patient Safety Agency

NPSA responds to incidents of handrub misuse

October 2008


The recent spate of news stories about the misuse of alcohol handrub has prompted the National Patient Safety Agency (NPSA) to remind trusts to be more selective about where they put dispensers.


Katherine Wilson, campaign lead for the NPSA-run cleanyourhands initiative said: “The NPSA recommends that alcohol handrub should only be used within the immediate contact area that a patient is being treated. Last month we updated our patient safety alert which highlights the need for all healthcare staff to clean their hands at the point of care as this is where there is the greatest risk of transferring infection.”


Alcohol-based handrub has been in use in the UK for over four years and its use at the point of care is the recognised best practice standard internationally. In hospitals, the point of care will usually be around the patient’s bed, their bedside locker or their chair, while in other settings this could be a treatment room, cot, chair, ambulance or the patient’s home.


“We also strongly recommend staff use personal dispensers, particularly if they treat children or mental health patients, as this further minimises risk of misuse. Hospitals that install handrub dispensers away from the point of care, including along corridors or at ward entrances, must take all necessary safety and storage precautions.”





Media enquiries to Paul Cooney in the NPSA Communications Department on 020 7927 9351 / paul.cooney@npsa.nhs.uk or Amelia Lyons on 020 7927 9580 / amelia.lyons@npsa.nhs.uk.


The patient safety alert “Clean Hands Save Lives” is based on the first hand hygiene alert issued by the NPSA in September 2004 and is revised in line with the current best practice guidelines for 2008. It is the first in the “Worth Repeating” series which the NPSA has introduced to raise awareness of important patient safety issues.


From 1 November 2003 of 15 July 2008, the NPSA’s National Reporting and Learning System (NRLS) received 379 reports of patient safety incidents involving alcohol handrub in NHS trusts in England and Wales. Of these the majority were reported as low or no harm. The NRLS is designed for confidential reporting of patient safety errors and systems failures by health professionals across England and Wales. The confidential data is analysed by the NPSA to identify national patient safety trends and priorities, and to develop practical solutions. The aim is to help the NHS to learn from things that go wrong.


In July 2008 the cleanyourhands campaign released a guidance DVD to all NHS trusts in England and Wales, demonstrating the correct procedures for hand hygiene.


The NPSA-run cleanyourhands campaign aims to improve the hand hygiene of healthcare workers and helps the NHS tackle healthcare associated infections. Since its launch in 2004, the campaign has been adopted by all NHS acute trusts in England and Wales, and has more than doubled the rate of hand hygiene. In July the campaign was extended to primary care, mental health, ambulance and care trusts.


The National Patient Safety Agency encompasses the National Research Ethics Service, National Reporting and Learning Service and the National Clinical Assessment Service. Our vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. Each division works within its sphere of expertise to improve patient outcomes.