COMMISSION STAFF WORKING DOCUMENT Detailed analysis of countries' reports on the implementation of the Council Recommendation (2009/C 151/01) on patient safety, including the prevention and control of healthcare associated infections Accompanying the document REPORT FROM THE COMMISSION TO THE COUNCIL ON THE BASIS OF THE MEMBER STATES' REPORTS ON THE IMPLEMENTATION OF THE COUNCIL RECOMMENDATION (2009/C 151/01) ON PATIENT SAFETY, INCLUDING THE PREVENTION AND CONTROL OF HEALTHCARE ASSOCIATED INFECTIONS.
Date: 2012-11-13
Institutions: European Commission
Subjects: health care system, health control, health risk, health service, in-service training, infectious disease, nursing staff, patient's rights

EUROPEAN 
COMMISSION 

Brussels, 13.11.2012  
SWD(2012) 366 final 

COMMISSION STAFF WORKING DOCUMENT 

Detailed analysis of countries' reports on the implementation of the Council 
Recommendation (2009/C 151/01) on patient safety, including the prevention and 
control of healthcare associated infections 

Accompanying the document 

REPORT FROM THE COMMISSION TO THE COUNCIL ON THE BASIS OF THE 
MEMBER STATES' REPORTS ON THE IMPLEMENTATION OF THE COUNCIL 
RECOMMENDATION (2009/C 151/01) ON PATIENT SAFETY, INCLUDING THE 
PREVENTION AND CONTROL OF HEALTHCARE ASSOCIATED INFECTIONS.

{COM(2012) 658 final} 

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TABLE OF CONTENTS 

COMMISSION STAFF WORKING DOCUMENT Detailed analysis of countries' reports on 
the implementation of the Council Recommendation (2009/C 151/01) on patient safety, 
including the prevention and control of healthcare associated infections.................................. 4 

Introduction ................................................................................................................................ 4 

Methods...................................................................................................................................... 6 

Participants ................................................................................................................................. 7 

Results ........................................................................................................................................ 8 

1. 

1.1. 

1.2. 

1.3. 

1.4. 

1.5. 

1.6. 

1.7. 

1.8. 

2. 

General patient safety................................................................................................... 8 

Establishment and development of national policies and strategies on patient safety. 8 

Empower and inform citizens and patients ................................................................ 14 

Establish or strengthen blame-free reporting and learning systems on adverse events
.................................................................................................................................... 17 

Promote education and training of healthcare workers on patient safety .................. 21 

Classify and measure patient safety at Community level, by working with each other 
and with the Commission........................................................................................... 24 

Share knowledge, experience and best practice by working with each other and with 
the European Commission and relevant European and international bodies............. 25 

Develop and promote research on patient safety ....................................................... 28 

Summary of implementation progress ....................................................................... 30 

Prevention and control of healthcare associated infections ....................................... 32 

2.1. 

Strategies, action plans, indicators and inter-sectoral mechanisms ........................... 32 

2.1.1.  Strategies for the prevention and control of HAI....................................................... 32 

2.1.2.  Action plans ............................................................................................................... 34 

2.1.3. 

Indicators.................................................................................................................... 40 

2.1.4. 

Inter-sectoral mechanisms or equivalent systems ...................................................... 44 

2.2. 

Prevention and control measures at national or regional level to support the 
containment of healthcare associated infections ........................................................ 46 

2.3. 

Infection prevention and control at the level of healthcare institutions ..................... 51 

2.3.1.  Governance arrangements for hospitals ..................................................................... 51 

2.3.2.  Governance arrangements for nursing homes............................................................ 52 

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2.3.3.  Qualified personnel .................................................................................................... 53 

2.4. 

Surveillance systems .................................................................................................. 55 

2.4.1.  National or regional networks for surveillance.......................................................... 55 

2.4.2.  Alert and reporting systems ....................................................................................... 56 

2.5. 

Education and training of healthcare workers............................................................ 57 

2.5.1.  Education and training of infection control staff ....................................................... 58 

2.5.2.  Education and training of healthcare workers............................................................ 58 

2.6. 

2.7. 

2.8. 

Information to patients by healthcare institutions...................................................... 58 

Research initiatives .................................................................................................... 59 

Impact of the Recommendation ................................................................................. 60 

2.8.1.  Reported impact ......................................................................................................... 60 

2.8.2. 

Indicators that could be used to assess the impact of the Recommendation on 
prevention and control of HAI activities and outcomes in hospitals ......................... 61 

Conclusions .............................................................................................................................. 63 

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COMMISSION STAFF WORKING DOCUMENT 

Detailed analysis of countries' reports on the implementation of the Council 
Recommendation (2009/C 151/01) on patient safety, including the prevention and 
control of healthcare associated infections 

Accompanying the document 

REPORT FROM THE COMMISSION TO THE COUNCIL ON THE BASIS OF THE 
MEMBER STATES' REPORTS ON THE IMPLEMENTATION OF THE COUNCIL 
RECOMMENDATION (2009/C 151/01) ON PATIENT SAFETY, INCLUDING THE 
PREVENTION AND CONTROL OF HEALTHCARE ASSOCIATED INFECTIONS. 

INTRODUCTION 

Following  a  proposal  from  the  Commission,  the  Council  adopted  in  June  2009  the  Council 
Recommendation  on  patient  safety,  including  the  prevention  and  control  of  healthcare 
associated infections (2009/C 151/01)1, hereinafter referred to as the Recommendation. This 
Recommendation is composed of a chapter on general patient safety issues and a chapter on 
the prevention and control of healthcare associated infections (HAI). 

In the chapter on patient safety, Member States are asked to put in place a series of measures 
with  a  view  to  minimizing  harm  to  patients  receiving  healthcare.  Such  measures  should 
include  supporting  development  of  national  policies  and  programmes  on  patient  safety, 
empowering  and  informing  patients,  establishing  or  strengthening  blame-free  reporting  and 
learning systems on adverse events, promoting education and training of healthcare workers, 
and developing research. 

In  addition,  the  Recommendation  invites  the  Member  States  to  work  together  and  with  the 
Commission  on  classifying  and  codifying  patient  safety  at  EU  level  as  well  as  on  sharing 
knowledge, experience and best practice. 

In  the  chapter  on  the  prevention  and  control  of  healthcare  associated  infections,  Member 
States are asked to adopt and implement a strategy at the appropriate level for the prevention 
and  control  of  HAI  and  to  consider  setting  up  an  inter-sectoral  mechanism  or  equivalent 
system  for  the  coordinated  implementation  of  such  strategy.  It  is  recommended  that  the 
strategy  pursues  the  following  objectives:  infection  prevention  and  control  measures  at 
national/regional  level,  enhance  infection  prevention  and  control  at  the  level  of  healthcare 
institutions,  establish  or  strengthen  surveillance  systems,  foster  education  and  training  of 
healthcare workers, improve the information to patients by healthcare institutions, and support 
research. 

Three  years  after  its  adoption,  the  Commission  has  summarized  the  main  actions  taken  at 
Member  State  and  European  Union  level  in  a  Report  to  the  Council,  on  the  basis  of  the 
information provided by the Member States on the implementation of the Recommendation. 

1 

OJ C 151, 3.7.2009, p. 1–6. 

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The Report is accompanied by this Commission Staff Working Document providing a more 
detailed technical analysis of the replies received both at the national and regional level. 

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METHODS 

The European Commission elaborated a questionnaire for Member States based on the text of 
the  Recommendation.  The  questionnaire  was  composed  of  two  parts,  referring  to  two 
Chapters  of  the  Recommendation:  Part  I  referred  to  Chapter  I  on  general  patient  safety  and 
Part II referred to Chapter II on the prevention and control of healthcare associated infections. 
Part  I  was  discussed  with  the  Commission-led  expert  group  –  Working  Group  on  Patient 
Safety and Quality of Care and the amendments proposed by the Group were integrated in the 
final  version.  Part  II  was  reviewed  by  a  small  number  of  Member  State  experts.  As  far  as 
possible, the questionnaire was developed in a format conducive to producing a concise and 
comparable report to improve data collation and analyses. 

The European Commission sent the questionnaire to Member States in April 2011. Member 
States  were  encouraged  to  distribute  the  questionnaire  to  regional  level  as  appropriate.  The 
preliminary findings of Part I were presented for review and comments at the Patient Safety 
Working Group meeting in Brussels in November 2011. The preliminary findings of Part II 
were presented at the Joint Annual Meeting of the Antimicrobial Resistance and Healthcare-
Associated Infections Networks in Warsaw in November 2011. Detailed analyses of data took 
place between November 2011 and February 2012. 

In  view  of  the  planned  adoption  in  November  2012  instead  of  June  2012  the  Commission 
asked Member  States to  update,  if relevant the information on general patient safety part in 
July 2012. Update of analysis took place in September 2012. 

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PARTICIPANTS 

For  Part  I  (general  patient  safety  issues)  of  the  questionnaire,  the  Commission  received  33 
responses, from: 

– 

– 

– 

27 Member States and Norway; 

five Spanish regions (Andalusia, Basque Country, Catalonia, Community of Madrid 
and Extremadura); 

14 Member States (AT, BE, CY, CZ, DE, DK, HU, IE, IT, LV, MT, PL, SE, SI) and 
4  Spanish  regions  (Basque  Country,  Catalonia,  Community  of  Madrid  and 
Extremadura) sent updated information. 

For  Part  II  (the  prevention  and  control  of  healthcare  associated  infections)  of  the 
questionnaire, the Commission received 42 responses, from: 

– 

– 

– 

– 

26 Member States and Norway at national level; 

one  Member  State  (UK)  at  regional  level  only,  from  two  regions:  England  (for  the 
NUTS 1 level statistical regions of England (East Midlands, East of England, Greater 
London, North East England, North West England, South East England, South West 
England, West Midlands, Yorkshire and the Humber)) and Scotland (NUTS 1 level); 

five Spanish regions at NUTS 2 level (Andalusia, Basque Country, Catalonia, Ceuta 
and Melilla, Community of Madrid) 

eight Italian regions at NUTS 2 level (Aosta Valley, Apulia, Autonomous Province 
of Trento, Emilia-Romagna, Friuli-Venezia Giulia, Liguria, Lombardy, Piedmont). 

In the present document the term ‘Member States’ is used when the reference is made to EU 
Member States. Every time Norway is included, the term ‘countries’ is used. 

When a question was answered in similar way by the national and regional level of a Member 
State, the response was counted as a country response. Similar responses from the UK regions 
on Part II were counted as a country response. 

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RESULTS 

1. 

GENERAL PATIENT SAFETY 

1.1. 

Establishment  and  development  of  national  policies  and  strategies  on  patient 
safety 

Twenty four countries (BE, BG, CZ, DE, DK, EE, EL, ES, FI, FR, HU, IE, IT, LT, LU, LV, 
MT, NL, NO, PT, SE, SI, SK, UK) and four regions (Basque Country, Catalonia Community 
of  Madrid  and  Extremadura)  reported  to  have  developed  national  and/or  regional  strategies 
and  programmes  on  patient  safety,  either  specific  ones  or  as  part  of  other  public  health 
policies.  In  two  countries  (AT,  RO)  and  one  region  (Andalusia)  such  a  strategy  was  under 
preparation. Two Member States (CY, PL) did not have a patient safety strategy nor were they 
in the process of preparing one. 

Three Member States (FR, NL, SK) reported to have a cross-border patient safety strategy, in 
addition to the national one.  

Twenty one Member States (BE, CZ, DE, DK, EE, ES, FI, FR, HU, IE, IT, LT, LU, LV, MT, 
NL,  PT,  SE,  SI,  SK,  UK)  and  three  regions  (Basque  Country,  Catalonia  and  Extremadura) 
developed  or  are  developing  indicators  or  mechanisms  to  assess  to  what  extent  different 
elements  of  patient  safety  strategy  or  programme  are  implemented.  Most  of  them  target 
hospital care and only a few of them focus on both inpatient and outpatient care.  

The reported indicators/mechanisms include: 

• 

• 

• 

• 

• 

• 

• 

number of reporting and learning systems in hospitals; 

number of hospitals applying patient safety standards; 

number of hospitals measuring patient safety culture 

number of evaluation of the citizens complaints and suggestions 

number  of  hospitals  having  in  place  registers  of  after  surgery  complications  and 
adverse reactions of drugs 

monthly performance reports from administrator of the public health system 

regular inspections against standards by a quality authority 

Several  Member  States  also  reported  about  indicators  in  use  at  healthcare  provider  level. 
These  include:  healthcare  associated  infections  rate,  alcohol-based  product  consumption, 
screening  of  nutritional  disorders,  implementation  of  surgical  checklist,  single  sheet  of 
therapy and presence of a risk manager in the facilities. 

The Recommendation asks Member States to include the following elements as part of patient 
safety policies and programmes: 

(a) 

Designating  the  competent  authority  or  authorities  or  any  other  competent  body  or 
bodies responsible for patient safety 

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Twenty one countries have reported having such an authority in place as part of the strategy 
on patient safety: 16 countries (CZ, DE, EE, ES, FI, HU, IE, LT, LU, MT, NL, NO, PT, SE, 
SI, UK) at national level only; four at both national and regional level (DK, FR, IT, SK) and 
one  (EL)  only  at  regional  level.  A  competent  authority  was  also  identified  in  all  reporting 
regions.  Moreover,  four  Member  States  (AT,  BE,  BG,  PL)  identified  a  competent  authority 
but not as a part of general patient safety strategy. 

Figure 1: Competent authorities/bodies identified by countries 

In 19 countries (AT, BG, CZ, DE, DK, EL, ES, FI, FR, HU, IE, IT, LT, NL, NO, PL, PT, SK, 
UK)  and  four  regions  (Andalusia,  Catalonia,  Community  of  Madrid  and  Extremadura)  the 
authority was officially created by a legal act. 

The  main  functions  of  competent  authorities  are:  identification  and  dissemination  of  best 
practices, collecting information about patient safety programmes, development of guidelines 
on patient safety and promotion of safe practices (Table 1). The following functions are the 
least  covered:  information  for  patients  and  their  relatives,  research  on  patient  safety  and 
development of patient safety systems. 

Table 1: Functions covered by the competent authorities 

Functions 

Collecting information about patient safety programmes in place 

Collecting and analysing information about patient safety outcomes 

Education and training of healthcare workers 

Countries 

Regions 

(total = 28) 

(total = 5) 

24 

21 

21 

5 

5 

5 

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Development of patient safety standards or other safety measures 

Identification and dissemination of best practices 

Development of guidelines on patient safety 

Information for healthcare decision makers 

Information for healthcare workers 

Information for patients and their relatives 

Development of patient safety systems 

Promotion of safe practices 

Research on patient safety 

Other 

23 

25 

24 

23 

23 

20 

18 

24 

19 

10 

5 

5 

4 

4 

5 

4 

4 

5 

5 

1 

In 23 countries (AT, BE, CZ, DE, DK, EE, ES, FI, FR, HU, IE, IT, LT, LU, MT, NL, NO, 
PL,  PT,  SE,  SI,  SK,  UK)  and  in  three  regions  (Andalusia,  Catalonia  and  Extremadura) 
competent  authorities  collaborate  with  the  European  Commission  and/or  with  other  EU 
Member States. 

(b) 

Embedding patient safety as a priority issue in health policies and programmes 

All the countries and regions reported patient safety was a priority issue embedded in public 
health policies. 

In eight countries (BG, EE, FI, HU, IE, IT, NO, UK) and three regions (Andalusia, Basque 
Country and Extremadura), patient safety is part of a national health strategy or programme; 
in  nine  others  (AT,  CZ,  DE,  ES,  FR,  PT,  RO,  SI,  SK)  and  in  one  region  (Community  of 
Madrid)  it  is  embedded  in  strategies  of  healthcare  quality  improvement,  including 
accreditation  programmes.  Other  policies  covering  patient  safety  include:  haemovigilance 
(BE  and  MT),  pharmacovigilance  (DE,  PL  and  Catalonia),  medication  policy  (FR  and 
Catalonia), health insurance (FR), health strategy on medical professions (DE), patient rights 
(LT), patient empowerment and increasing health literacy (NL). 

(c) 

Supporting the development of safer and user-friendly systems, processes and tools, 
including the use of information and communication technology 

Twenty two countries (BE, BG, CZ, DE, DK, EE, ES, FI, FR, HU, IE, IT, LT, LU, MT, NL, 
NO,  PT,  SE,  SI,  SK,  UK)  and  one  region  (Extremadura)  reported  that  such  tools  were 
developed  in  the  framework  of  the  overall  strategy  on  patient  safety.  Among  those,  three 
Member States (FR, DE, NL) developed tools also for cross-border use.  

(d) 

Regularly reviewing and updating safety standards and/or best practices applicable to 
healthcare provided on their territory 

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Fifteen  Member  States  (AT,  CZ,  DE,  DK,  EE,  ES,  FR,  HU,  IE,  IT,  LT,  PT,  PL,  SE,  UK) 
reported  having  in  place  regularly  updated  patient  safety  standards.  Patient  safety  standards 
were also in place in all reporting regions. 

In 11 out of the 15 Member States (AT, CZ, DE, DK, EE, FR, IE, IT, LT, PT, UK) and in four 
regions  (Andalusia,  Catalonia,  Community  of  Madrid  and  Extremadura)  standards  are 
mandatory  at  national/regional  and/or  healthcare  provider  level.  In  four  remaining  Member 
States  (ES,  HU,  PL,  SE)  and  in  one  region  (Basque  Country)  patient  safety  standards  are 
recommended, but not mandatory. 

Near  two  thirds  of  reported  standards  were  updated  less  than  one  year  ago,  for  others  an 
update has been done between two and five years ago. 

Eighteen Member States (AT, BE, BG, CY, CZ, DE, DK, ES, FI, FR, IE, LT, NL, PT, RO, 
SE,  SI,  UK)  and  three  regions  (Basque  Country,  Catalonia  and  Community  of  Madrid) 
reported having in place and regularly updating patient safety measures other than standards, 
for  example:  identification  of  best  practice,  setting  patient  safety  targets  for  healthcare 
facilities, hand hygiene campaign, programme to prevent confusion of patient and confusion 
of  surgical  procedure,  evidence  based  clinical  guidelines,  national  patient  safety 
recommendation, patient charter, accreditation procedure with elements of patient safety and 
measurement of patient safety culture in hospitals. 

Five  countries  (EL,  LU,  LV,  NO,  SK)  did  not  report  about  any  patient  safety  standards  or 
other measures in place and one Member State (MT) reported about recent implementation of 
standards specific for blood transfusion.  

In 18 Member States (AT, BE, BG, CZ, DE, DK, EE, ES, FI, FR, IE, LT, MT, NL, PL, PT, 
SE, UK) and in four regions (Andalusia, Catalonia, Community of Madrid and Extremadura) 
patients  are  informed  about  safety  measures  (standards  or  other).  As  presented  at  Figure  2, 
information  is  the  most  frequently  provided  by  health  professionals,  followed  by  public 
websites and information on request from management of healthcare setting. Other reported 
ways  of  informing  patients  include:  flyers,  dedicated  boards  in  hospitals  or  articles  in 
specialized  journals.  Patient  organisations  and  citizens'  networks  also  contribute  to 
dissemination of information about patient safety measures. 

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Figure 2: The ways of providing information to patients 

Member States were asked if they would find useful guidelines on how to build and introduce 
patient safety standards. The large majority (24) of countries and all the regions agreed such 
guidelines  would  be  useful.  Only  FR,  HU,  LV  and  NL  did  not  confirm  their  interest  in 
guidelines. 

(e) 

Encouraging health professional organisations to have an active role in patient safety 

Twenty two countries (BE, BG, CZ, DE, DK, EE, EL, ES, FI, FR, IE, IT, LT, LU, MT, NL, 
NO, PT, SE, SI, SK, UK) and all regions reported having in place mechanisms to encourage 
an active role of health professional organisations in patient safety, at national and /or regional 
level. 

(f) 

Including  a  specific  approach  to  promote  safe  practices  to  prevent  the  most 
commonly  occurring  adverse  events  such  as  medication-related  events,  healthcare 
associated infections and complications during or after surgical intervention 

Table 2 shows in which fields countries and regions took actions to prevent complications and 
adverse events.  

Table 2: Areas of actions to prevent complications and adverse events 

Type of action 

Countries 

Regions 

(total = 28) 

(total = 5) 

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Medication related events 

Complications during or after surgical interventions 

Complication  and  adverse  events  during  and  after  blood/blood  components 
transfusion 

Complication and adverse events during and after tissue transplantation 

Complication and adverse event during and after organ transplantation 

Complication and adverse event during and after organ living donation 

24 

24 

23 

21 

21 

20 

5 

5 

3 

2 

2 

2 

Twenty countries (AT, BE, BG, CY, CZ, DE, DK, EE, ES, FI, FR, IE, IT, LU, MT, NL, NO, 
PL,  SK,  UK)  and  all  regions  developed  specific  actions  in  two  areas  required  by  the 
Recommendation, i.e. medication related events and complications during and after surgical 
intervention.  

Fifteen countries (AT, BG, CZ, DE, DK, ES, FI, FR, IE, IT, LU, NO, PL, SK, UK) and two 
regions (Catalonia and Community of Madrid) have put in place specific actions in all above 
areas and five Member States (EL, HU, LV, PT, SI) have put in place actions only in one of 
six areas.  

Additional comments: 

In  addition  to  elements  required  by  the  Council  Recommendation,  18  of  existing  national 
strategies and policies on patient safety (BE, CZ, DE, DK, EE, ES, FI, FR, HU, IE, IT, LT, 
NL, NO, PT, SE, SI, UK) and four regions (Andalusia, Catalonia, Community of Madrid and 
Extremadura) cover the issues related to patient involvement in patient safety. 

Countries and regions were asked to add further comments on this part of the questionnaire. 
The  comments  confirmed  that  development  of  patient  safety  strategies  or  programmes  is 
interpreted  and  carried  out  by  countries  in  a  heterogeneous  way:  from  very  focused  patient 
safety  strategies  to  inclusion  of  patient  safety  in  policies  on  healthcare  quality  or  patient 
rights.  Some  countries  do  not  develop  national  policies  but  leave  to  hospitals  introducing 
patient safety measures. Finally, in some Member States national strategy takes the form of 
legislation, while in other the main focus is on less formal networks and platforms.  

As reported in Table 3, the main obstacles to full implementation of patient safety strategies 
or  programmes  were  the  financial  constraints,  other  pressing  issues  on  political  agenda  and 
the insufficient time between the adoption of the Recommendation and the time of reporting. 
Other  obstacles  included:  insufficient  awareness  among  professionals  about  the  need  of 
patient  safety  culture  or  lack  of  continuity  of  public  health  priorities  due  to  government 
change. 

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Table 3: The most reported obstacles to a full implementation 

Obstacles 

Insufficient time between the adoption of the Recommendation and the reporting 

Financial constraints 

Other pressing issues on the political agenda (e.g. financial crisis) 

Other 

1.2. 

Empower and inform citizens and patients 

Countries 

Regions 

(total = 28) 

(total = 5) 

14 

15 

15 

8 

3 

3 

2 

2 

(g) 

Involving  patient  organisations  and  representatives  in  the  development  of  policies 
and programmes on patient safety at all appropriate levels 

Twenty countries (AT, BE, BG, CZ, DE, DK, EE, ES, FI, FR, IE, IT, LT, LV, NL, NO, PL, 
SE,  SK,  UK)  and  four  regions  (except  Basque  Country)  reported  they  involve  patient 
organisations in development of patient safety policies. In 14 of these countries (AT, DE, DK, 
EE, ES, FI, FR, IE, IT, LT, NO, SE, SK, UK) involving patient organisations is required by 
legislation  or  administrative  decisions.  Patient  organisations  are  mostly  involved  at  national 
and/or  regional  level  and  less  at  healthcare  facility  level.  Two  Member  States  (AT,  FR) 
involve  them  in  developing  patient  safety  policies  at  all  levels:  transnational,  national, 
regional, local and healthcare facility level. 

In 19 countries (AT, BG, CZ, DE, DK, EE, ES, FI, FR, IE, IT, LT, LV, NL, NO, PL, SE, SK, 
UK) and in four regions (except Basque Country) patient organisations are encouraged to give 
feedback  about  their  involvement,  in  most  cases  anytime  they  feel  it  is  needed.  Figure  3 
shows the most common ways to collect feedback. 

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Figure 3: The ways of capturing feedback from patient organisations 

Eight Member States (CY, EL, HU, LU, MT, PT, RO, SI) and Basque Country did not report 
any provisions involving patient organisations in developing policies on patient safety.  

(h) 

Dissemination of information to patients on patient safety issues 

Member  States  were  recommended  to  disseminate  information  to  patients  on  patient  safety 
standards  in  place,  safety  measures  in  place  to  reduce  or  prevent  errors,  right  to  informed 
consent to treatment, complaint procedures, and available remedies and redress. 

In all reporting countries at least one of above elements is communicated to patients, but only 
in  five  Member  States  (CZ,  DE,  ES,  NL  and  UK)  and  in  two  regions  (Catalonia  and 
Community of Madrid) patients are provided with all of them. 

The most disseminated information is right to informed consent (in all 28 countries, and in all 
the  regions),  followed  by  complaint  procedures  (in  27  countries  except  HU,and  in  all  the 
regions). 

Information about patient safety standards is communicated to patients only in seven Member 
States  (CZ,  DE,  ES,  LT,  NL,  PT,  UK)  and  three  regions  (Catalonia,  Community  of  Madrid 
and Extremadura). 

Additionally, 16 countries (AT, CZ, DK, EE, FR, IT, LT, LU, LV, MT, NO, PL, PT, RO, SI, 
UK) and three regions (Catalonia, Community of Madrid and Extremadura) make the list of 
accredited healthcare institutions available to patients. 

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Figure  4  presents  an  overview  of  categories  of  information  provided  to  patients  by  all  33 
respondents (both the countries and the regions). 

Figure 4: Categories of information provided to patients 

Sixteen countries (BE, BG, CY, CZ, DE, DK, ES, FR, IE, LV, MT, NL, NO, PT, RO, SK) 
and all the regions reported that they have in place specific procedures to inform non-resident 
patients  about  patient  safety  standards  or  other  measures.  However,  no  further  details  were 
given on these procedures except two examples of translation services available on a case-by-
case basis. 

Twenty  three  countries  (except  CY,  EL,  HU,  IT,  PL)  and  two  regions  (Catalonia  and 
Community of Madrid) reported to have in place mechanisms to capture patients' feedback on 
the  availability  and  the  accuracy  of  information  provided.  They  can  be  divided  into  two 
categories: feedback captured at discharge from hospital (e.g. written or on-line questionnaire) 
and feedback captured periodically at national level (e.g. annual patient experience survey). 

In five Member States (FI, IE, LV, NO, UK) patients have possibility to give their feedback in 
proactive  and  continuous  manner  (e.g.  posting  the  comments  on  a  dedicated  website  or 
meeting patient ombudsman or complaint officer present in each healthcare setting). 

(i) 

Considering the possibilities  of development of core  competencies in  patient safety 
for patients 

Twelve Member States (CZ, DE, DK, ES, FI, FR, IE, IT, LT, NL, SE, SK) and three regions 
(Catalonia,  Community  of  Madrid  and  Extremadura)  reported  having  developed  core 
competencies for patients. The core competencies have been disseminated to patients mostly 
using publicity, ICT tools or paper documents. 

EN 

16 

   EN 

 
 
 
The following examples  were reported as part of  core competencies:  dedicated websites for 
both health professionals and citizens to compare hospitals (DK); guidelines to a patient for 
safe care in hospital, explaining to a patient how to follow and monitor the process of his/her 
treatment  (FI);  information  about  prevention  of  healthcare  associated  infections  and  about 
WHO  actions:  Safe  Surgery  Checklist,  Clean  Your  Hands  (IE);  check-lists  or  guides  for 
patient  safety  for  a  patient  and  his/her  relatives  (FI,  IT,  NL);  programmes  of  therapeutic 
patient  education  for  patients  with  chronic  diseases  (FR);  translation  of  national  guidelines 
into  an  easy  comprehensible  language  for  patients  (DE);  information  to  patients  about 
patients'  rights  (SE,  IE);  developing  recommendations  to  patients  on  patient  safety 
(Community  of  Madrid);  education  of  patients  and  information  about  patient  safety  and 
quality of healthcare (DE); training patients on safe practices in patient care: safe medication 
use, infection prevention and communication skills (ES). 

In most cases (9 out of 11 Member States and three regions) the core competencies on patient 
safety  are  embedded  in  programmes  and  policies  on  patient  rights,  quality  of  healthcare  or 
patient empowerment. However, two Member States (ES and FI) have in place specific core 
competencies for patients on patient safety. 

Eight Member States (BE, BG, CY, FI, MT, PT, SI, UK) and three regions (Basque Country, 
Catalonia  and  Extremadura)  have  plans  to  implement  actions  and  mechanisms  regarding 
empowering citizens and patients within the next years. 

Eight  Member  States  (BE,  BG,  CZ,  FI,  HU,  PT,  RO,  SI)  and  two  region  (Catalonia  and 
Extremadura)  reported  difficulties  in  implementing  the  provisions  related  to  empowering  of 
patients. Besides insufficient time since the adoption and financial constraints, they include: 
insufficient  time  of  health  professionals  and  insufficient  experience  of  decision-makers  in 
involving  patients;  difficulties  to  find  umbrella  patient  organisations  to  work  with  or 
insufficient  interest  from  patient  organisations  to  get  involved  in  patient  safety  issues. 
However,  two  Member  States  (BE  and  SI)  reported  that  patient  empowerment  was  an 
important objective of health strategies to come shortly.  

1.3. 

Establish  or  strengthen  blame-free  reporting  and  learning  systems  on  adverse 
events 

Twenty two Member States (AT, BE, CY, CZ, DE, DK, EE, ES, FI, FR, HU, IE, IT, LU, LV, 
NL,  NO,  PL,  PT,  SE,  SK,  UK)  and  two  regions  (Andalusia  and  Catalonia)  have  in  place 
reporting and learning systems (RLS) and four countries (BG, LT, MT, SI) and three regions 
(Basque  Country,  Community  of  Madrid  and  Extremadura)  are  in  process  of  establishing 
them (Figure 5). They operate at all levels; national level (17 RLS), healthcare provider level 
(13 RLS), local level (10 RLS) and regional level (8 RLS). Two Member States (DK and FR) 
have in place cross-border systems. 

EN 

17 

   EN 

 
Figure 5: Reporting and learning systems in place as reported by 33 respondents 

Among Member States having in place multiple reporting and learning systems (13 Member 
States), only six (CZ, DE, IT, SE, SK, UK) have these systems interoperable. 

(j) 

Provide  information  on  the  extent,  types  and  causes  of  errors,  adverse  events  and 
near misses 

The  existing  systems  mostly  provide  information  about  causes  of  adverse  events  (24  RLS), 
number  of  adverse  events  by  type  (23  RLS)  and  globally  (19  RLS).  Other  collected 
information include: patient outcome (BE, Andalusia); organisational outcome (BE); number 
of events by their severity (CZ, ES); setting of origin, description and prevention of adverse 
events incidents (CZ); number of patients complaints and cases of malpractice (EE); age and 
sex  of  the  harmed  person;  medical  field;  place  and  context  of  the  adverse  event;  result  of 
event; frequency of the event; factors contributing to the adverse event; who reported about 
the event (DE, Andalusia); information on good practice to avoid adverse events (Andalusia); 
improvement actions for future (DE, Andalusia, Community of Madrid).  

The type of information most or least frequently collected and provided by the reporting and 
learning systems is shown in Figure 6. In 14 Member States (BE, CY, CZ, DE, DK, EE, ES, 
FR, IE, LU, NL, PT, SK, UK) and in all regions reporting and learning systems provide three 
or more types of information. 

EN 

18 

   EN 

 
 
 
Figure 6: Types of information provided by RLS 

(k) 

Encourage  healthcare  workers  to  actively  report  through  the  establishment  of  a 
reporting environment which is open, fair and non-punitive 

In 18 out of 26 countries (AT, BE, CZ, DE, DK, ES, FI, FR, HU, IE, IT, LU, NL, NO, PL, 
SE, SI, UK) and in three regions (Andalusia, Basque Country and Community of Madrid) the 
reporting and learning systems are differentiated from disciplinary systems and procedures for 
healthcare  workers  in  order  to  ensure  non-punitive  context  of  reporting.  Near  all  countries 
(except  BG)  and  all  regions  having  reporting  systems  in  place  took  actions  to  increase 
reporting on adverse events by health workers.  

Actions can be divided into four categories: 

(1) 

(2) 

information  to  health  workers  (e.g.  a  brochure-guide  for  healthcare  providers 
on how to implement reporting and learning systems, workshops on reporting 
and  analysing  incidents,  clear  explanation  of  the  purpose  of  the  systems  to 
health professionals);  

technical help in implementing and using reporting and learning systems (e.g. 
nominated  patient  safety  expert  for  procedures  and  training  at  hospital  level, 
dedicated organisation offering technical help for creating systems at national 
level);  

(3) 

creating of blame free culture (e.g. anonymous reporting, discussions of patient 
safety incidence among professionals);  

(4)  binding  measures  (e.g.  mandatory  reporting,  reporting  as  quality  criterion  in 

certification procedure). 

EN 

19 

   EN 

 
 
 
Reporting of adverse events by health professionals increased over the last two years in two 
thirds of Member States having systems in place and in three regions. In six Member States 
(BG, FR, MT, NO, PL, PT) and in Extremadura region this information is not available. 

(l) 

Provide  opportunities  for  patients,  their  relatives  and  other  informal  caregivers  to 
report their experience 

In 13 out of 25 Member States (BE, BG, CZ, DE, DK, EE, FI, LU, MT, SE, SK, NL, UK) and 
in two regions (Andalusia and Catalonia) reporting and learning systems provide opportunity 
for patients and their families to report on adverse events.  

Moreover, only 11 Member States (CY, CZ, DE, EE, FI, IE, IT, NL, SE, SK, UK) and three 
regions  (Andalusia,  Catalonia  and  Extremadura)  collect  information  about  the  reporting  by 
patients.  In  six  Member  States  (DE,  EE,  ES,  IE,  FI,  NL)  and  in  Andalusia  such  reporting 
increased over the last two years. CZ reported that though a possibility for patients to report 
exists, it is not used due to lack of patients' awareness of such an option.  

(m) 

Complement other safety reporting systems whilst avoiding multiple reporting where 
possible 

Where  the  reporting  and  learning  systems  are  in  place,  most  are  differentiated  from  other 
reporting  systems,  such  as  pharmacovigilance,  haemovigilance  (notification  of  serious 
adverse events and reactions during and after blood transfusion) and medical devices failure. 
They  are  also  differentiated,  though  in  fewer  Member  States  (19  out  of  24),  from  reporting 
systems on human tissues, cells and organs. 

Figure 7 provides an overview of reporting and learning systems in 28 reporting countries and 
five reporting regions. 

3

11

19

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

3

9

21

3

15

15

3

8

22

provide
extensive
information on
adverse events

are differentiated
from disciplinary
procedures

provide
oppoortunity for
patients to report

complement
other reporting
systems

yes

no or not known

no RLS

Figure 7: Overview of reporting and learning systems in reporting countries and regions 

EN 

20 

   EN 

 
 
In 15 (BE, CZ, DE, DK, ES, FR, IE, IT, LU, NL, PL, PT, SE, SK, UK) Member States the 
RLS  respond  to  at  least  three  out  of  the  four  requirements  of  the  Recommendation,  i.e.  1) 
provide  information  on  the  extent,  types  and  causes  of  adverse  events;  2)  are  differentiated 
from Member States' disciplinary systems and procedures for healthcare workers; 3) provide 
opportunities  for  patients  and  their  families  to  report;  and  4)  complement  other  safety 
reporting systems. 

Twelve  Member  States  (BE,  BG,  EL,  ES,  FI,  HU,  IE,  LT,  MT,  RO,  SI,  SK)  reported 
difficulties  in  implementing  the  blame  free  reporting  and  learning  systems.  These  can  be  of 
different  nature:  legal,  e.g.  the  establishment  of  a  blame  free  reporting  system  requires 
complex  modifications  to  the  regulatory  framework;  cultural,  e.g.  the  existence  of  strong 
blame culture which makes health professionals reluctant of displaying the errors due to fear 
of  punishment;  systemic,  e.g.  insufficient  leadership  and  commitment  of  the  hospital 
management  to  introduce  reporting  and  learning  systems  or  public/private  healthcare  mix. 
Several  Member  States  highlighted  lack  of  financial  resources  as  the  main  obstacle  to  the 
implementation. 

In the comments to this part of the questionnaire Member States recognised the urgent need of 
efficient reporting and learning systems on adverse events.  

1.4. 

Promote education and training of healthcare workers on patient safety 

Member States were asked whether they have promoted education and training of healthcare 
workers on patient safety over the last two years at national and/or regional level.  

All reporting countries (except LU) and all reporting regions reported having promoted such a 
training  which  was  mostly  addressed  to  medical  doctors  and  nurses  (in  26  countries  except 
LU, SE and in all the regions), to pharmacists (in 24 countries except LU, RO, SE, SI, and in 
all the regions) and to healthcare managers (in 24 countries except LU, LV, NO, SE and in all 
the regions) – Figure 8. 

EN 

21 

   EN 

 
100%

2

2

4

4

i

s
n
o
g
e
R
d
n
a
s
e
i
r
t
n
u
o
C

f
o
o
n

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

31

31

29

29

no

yes

23

10

medical
doctors

nurses

pharmacists

healthcare
managers

other
healthcare
workers

Figure 8: Professional groups to which education and training on patient safety have been promoted at 
national/regional between June 2009 and June 2011 

Only  nine  countries  (AT,  BE,  DE,  ES,  FR,  IE,  NO,  PT,  UK)  and  three  regions  (Andalusia, 
Community  of  Madrid,  Extremadura)  promoted  training  for  other  healthcare  workers,  for 
example  to  radiology  technicians,  radiotherapists,  risk  managers,  laboratory  technicians 
porters, cleaners and healthcare assistants. In two cases (BE and HU) training was promoted 
to teaching schools for nurses, to universities and to pharmaceutical companies. PL reported 
using  the  European  Cohesion  Fund  and  the  European  Social  Fund  to  promote  and  organise 
training. 

Six  Member  States  (BE,  EE,  ES,  FR,  IE,  PT)  and  three  regions  (Andalusia,  Community  of 
Madrid and Extremadura) targeted all above groups. 

(n) 

Encouraging multidisciplinary patient safety education and training of health workers 
in healthcare settings 

At  healthcare  setting  level,  24  countries  (except  CY,  EE,  EL,  HU)  and  all  the  regions 
launched initiatives encouraging patient safety training. They include campaigns and training 
offered  by  competent  authorities  for  medical  training,  by  universities,  by  professional 
organisations  or  by  human  resources  departments  in  hospitals.  They  may  take  form  of 
lectures,  seminars  (also  web  seminars),  conferences  and  teaching  modules,  including  e-
learning modules. 

(o) 

Embedding  patient  safety  in  undergraduate  and  postgraduate  education,  on-the-job 
training and the continuing professional education of health professionals 

Over half of the reporting countries (15 – AT, BG, CY, DK, EE, FI, FR, IE, IT, LV, MT, NO, 
PT, SK, UK) and four regions except Catalonia stated having in place formal requirements to 

EN 

22 

   EN 

 
 
 
 
 
 
include patient safety modules in one or more types of education. Patient safety modules are 
mostly offered for nurses and medical doctors as part of the postgraduate education, on-the-
job training and the continuing professional education.  

The  groups  the  least  targeted  are  healthcare  managers  with  only  between  five  and  nine 
countries or regions offering patient safety modules for this category of professionals.  

In general terms, if patient safety education is embedded in education and training (i.e. in 15 
countries),  this  is  mostly  in  the  framework  of  continuing  professional  development  and  the 
least in undergraduate education (Figure 9). 

15

13

13

9

15

14

14

11

13

11

12

10

13

12

9

7

7

8

9

5

Medical
doctors

Nurses

Pharmacists Healthcare
managers

Other
healthcare
workers

Continuing professional
education

On-the-job training

Postgraduate education

Undergraduate education

Figure 9: Formal requirements to include patient safety in the education and training of health 
professionals and other health workers 

Health workers have possibility to give their feedback on education and training in 14 out of 
15  countries.  This  can  include  feedback  on  the  training  offer  or  evaluation  of  individual 
training sessions. 

(p) 

Considering the development of core competencies in patient safety, namely the core 
knowledge, attitudes and skills required to achieve safer care, for dissemination to all 
healthcare workers and relevant management and administrative staff 

Member States were asked what kind of information related to patient safety was available for 
healthcare workers. 

All responding countries except one (SE) provide at least one of the three following types of 
information: patient safety standards, risk and safety measures in place to reduce errors, best 
practices in patient safety. In 11 Member States (AT, CY, CZ, DE, EE, ES, FR, LU, PT, NL, 
UK)  and  four  regions  (except  Andalusia)  healthcare  workers  have  access  to  all  above 
information, and in six Member States (EL, LV, PL, RO, SI, SK) only to one of three types. 

EN 

23 

   EN 

 
 
ICT systems are used to support patient safety education and training of healthcare workers in 
17 countries (BE, BG, CZ, DE, DK, ES, FI, FR, HU, IE, IT, LU, LV, NO, PT, NL, UK) and 
in all the regions. They vary from simple use of a slide presentation at a training session to 
dedicated ICT training platforms or e-learning interactive modules. 

In  10  Member  States  (BE,  BG,  EL,  FR,  FI,  HU,  IT,  PL,  SI,  SK)  and  Extremadura  region 
initiatives regarding education and training of healthcare workers on patient safety are under 
implementation and are to be accomplished within the next years. 

Specific obstacles to full implementation of the provisions regarding education and training in 
patient  safety  include:  insufficient  domestic  expertise  in  the  field  and  difficulties  to  access 
such  expertise  at  EU  or  international  level;  difficulties  to  modify  university  programmes, 
either  because  of  lack  of  collaboration  between  health  and  education  sector  and  no  interest 
from education institutions, or because of slow processes; need of legislative changes. 

Having commented this part of the questionnaire, respondents highlighted difficulties to asses 
the impact of training on behaviour and attitudes of health professionals. 

1.5. 

(q) 

Classify and measure patient safety at Community level, by working with each 
other and with the Commission 

To  develop  common  definitions  and  terminology  taking  into  account  international 
standardisation activities 

The  European  Commission  facilitated  exchange  of  information  on  related  initiatives  in  the 
Working  Group  on  Patient  Safety  and  Quality  of  Care.  The  Group  is  composed  of  all  EU 
Member  States,  representatives  of  EFTA  countries,  International  Organisations  (WHO, 
OECD  and  the  Council  of  Europe)  and  EU  umbrella  organisations  representing  patients, 
health professionals, healthcare managers and quality of care experts. 

This Group had a chance to discuss the work of the WHO on the International Classification 
for Patient Safety, as well as several examples of national activities on patient safety. Sixteen 
countries are involved in the WHO work on the international classification (BE, CZ, DE, DK, 
ES,  FI,  FR,  IE,  IT,  LV,  NL,  NO,  PT,  SE,  SK,  UK)  and  two  (BE  and  SI)  translated  the 
classification in their national languages. 

However, to date no classification on patient safety has been proposed at EU level. 

(r) 

To develop a set of reliable indicators 

The  European  Commission  has  continued  to  co-finance  the  project  on  healthcare  quality 
indicators, led by the OECD. In 2011, the project published for the first time six indicators on 
patient safety: two related to obstetric trauma and four related to procedural and postoperative 
complications2. Twenty countries (AT, BE, CZ, DK, ES, FI, FR, HU, IE, IT, LV, MT, NL, 
NO,  PL,  PT,  SE,  SI,  SK,  UK)  reported  they  were  involved  in  the  project  and  13  Member 
States  (BE,  DE,  DK,  ES,  FI,  FR,  IE,  IT,  NL,  PT,  SE,  SI,  UK)  are  collecting  comparable 
indicators on patient safety.  

2 

EN 

OECD 
http://www.oecd.org/dataoecd/6/28/49105858.pdf 

(2011)  Health 

a  Glance 

at 

2011:  OECD 

Indicators,  OECD  Publishing. 

24 

   EN 

 
                                                 
(s) 

To gather and share comparable data and information on patient safety outcomes in 
terms of type and number to facilitate mutual learning and inform priority setting 

The European Commission proposed to Member States three-year collaboration, in the form 
of  a  joint  action.  One  part  of  the  joint  action  consists  of  selecting  best  practices  on  patient 
safety at healthcare provider level and testing their implementation in other Member States. 
The joint action is partly built on a previous EU co-funded project – EU Network on Patient 
Safety (EUNetPaS). 

All  27  Member  States  and  Norway  are  involved  in  the  overall  joint  action,  including  22 
(except BE, CY, CZ, EE, LU, PT, SI) financially participating in the project. 

Table 4: countries' involvement in EU and international initiatives and projects on patient safety 

Initiative 

 Countries 

(total = 28) 

The Commission's Working Group on Patient Safety and Quality of Care 

The European Network on Patient Safety (EUNetPaS) 

Joint Action on Patient Safety and Quality of Care 

OECD Health Care Quality Indicators Project 

WHO work on International Classification 

None of them 

Other 

28 

25 

28 

20 

16 

0 

8 

Member  States  were  asked  to  report  obstacles  regarding  their  participation  in  the  various 
projects  and  working  groups  on  patient  safety.  They  declared  that  the  lack  of  knowledge, 
beyond the financial constraints, is the issue of a partial participation of their experts to the 
projects. Moreover, Member States highlighted usefulness of participating in the above listed 
projects which gives opportunity to exchange best practices among them. 

1.6. 

Share knowledge, experience and best practice by working with each other and 
with the European Commission and relevant European and international bodies 

At EU level, several above-mentioned fora and mechanisms have been facilitating knowledge 
sharing on patient safety among Member States, namely: 

• 

• 

The European Commission Working Group on Patient Safety and Quality of Care - 
since 2005; 

The  EU  Network  on  Patient  Safety  (EUNetPaS)  -  project  co-financed  under  the 
Health Programme in the years 2007-2010; 

EN 

25 

   EN 

 
 
• 

The  Joint  Action  on  Patient  Safety  and  Quality  of  Care  –  a  3-year  collaboration 
between EC and Member States co-financed under the Health Programme (started in 
2012) 

All  above  mechanisms  aim  at  helping  Member  States  to  share  knowledge  and  best  practice 
on: 

(a)  The establishment of efficient and transparent patient safety programmes with 

a view to addressing adverse events in healthcare 

(b)  The effectiveness of patient safety interventions and solutions at the healthcare 

setting level and the evaluation of the transferability of these 

(c)  Major patient safety alerts in a timely manner 

Member States  were asked to report in which areas identified by the Recommendation they 
collaborate  with  other  countries.  The  most  frequent  areas  of  collaboration  are:  the 
development of patient safety strategies and programmes, followed by developing blame-free 
reporting and learning systems and development and review of patient safety standards. The 
areas  the  least  covered  are:  disseminating  information  to  patients  about  patient  safety, 
developing  core  competencies  on  patient  safety  for  patients  and  developing  patient  safety 
elements  in  national  accreditation  programmes.  Table  5  shows  which  areas  are  subject  of 
collaboration. 

Table 5: Collaboration areas among Member States 

Areas of patient safety as identified by the 
Recommendation 

Collaborating 
countries 

Collaborating 
regions 

Examples of 
collaborating partners 

UK-FR-DK;  

BG-PL-LT-SI-NL-DK; 

CZ-SI-SK; 

FI-SE;  

1. Development of patient safety strategies and 
programmes 

20 

3 

DE-AT;  

PT-ES-Andalusia; 

IE-all 
appropriate 

countries 

as 

Community  of  Madrid  - 
other ES regions; 

UK-FR-DK;  

2.  Development  and  review  of  patient  safety 
standards 

15 

1 

DE-AT;  

PL-DK-NL-UK 

EN 

26 

   EN 

 
 
PT-ES-Andalusia;  

SK-CZ; 

IE-all countries 

Community  of  Madrid  - 
other ES regions; 

UK-FR-DK; 

IE-UK-DK 

CZ-SI-SK;  

DE-AT-FR-UK-NL; 

SK-CZ; 

SE-NO-DK-FI; 

Andalusia-PT;  

Community  of  Madrid  – 
Andalusia; 

SK-CZ; 

Andalusia-PT; 

IE-all countries  

UK-FR-DK;  

LT-LV; 

PT-ES-Andalusia;  

SE-DK; 

BE-DK; 

UK-FR-DK;  

3.  Developing  blame-free 
learning systems 

reporting  and 

15 

2 

4. Patient safety information and campaigns 

14 

3 

5.  Involving  patient  organisations  in  patient 
safety policies 

11 

2 

6. Encouraging reporting on adverse events by 
both healthcare workers and patients 

11 

2 

CZ-SI-SK-AT; 

7.  Developing  educational  modules  on  patient 
safety for health professionals 

11 

2 

DE-AT;  

PT-ES-Andalusia;  

BE-DK;  

UK-FR-DK-DE-SK; 

EN 

27 

   EN 

 
 
 
PT-ES-Andalusia;  

UK-FR-DE;  

2 

CZ-SI-SK; 

PT-ES-Andalusia;  

UK-FR-DE; 

2 

PT-ES-Andalusia;  

Community  of  Madrid  – 
Andalusia; 

CZ-SI-SK;  

2 

PL-NL-CZ; 

PT-ES-Andalusia;  

8. Disseminating information to patients about 
patient safety 

9.  Developing  core  competencies  on  patient 
safety for patients 

10.  Developing  patient  safety  elements  in 
national accreditation programmes 

9 

9 

9 

In addition: 

FR reported collaboration with all countries and all regions in all areas; 

NL reported collaboration with various countries in all areas; 

Catalonia reported collaboration with Spanish regions in all areas. 

Five Member States (CY, EL, HU, LU, MT) and Basque Country did not report collaboration 
in  any  of  listed  areas.  However,  HU  announced  collaboration  with  PL  in  near  future  on 
development and review of patient safety standards.  

In addition, 15 countries (AT, BG, DK, ES, FI, FR, HU, IE, NL, NO, PL, SE, SI, SK, UK) 
and  Andalusia  collaborate  on  patient  safety  with  non-EU  countries:  Albania,  Argentina, 
Australia,  Bosnia  and  Herzegovina,  Brazil,  Canada,  Colombia,  Costa  Rica,  Croatia,  Egypt, 
Ethiopia, Georgia, Macedonia, Malawi, Mexico, Moldova, New Zealand, Peru, Switzerland, 
Turkey, Uganda, Ukraine and the USA. Cooperation with non-EU countries cover: reporting 
and  learning  systems,  outcome  indicators,  accreditation  and  certification  of  healthcare 
providers,  performance  measurement,  education  in  patient  safety,  specific  patient  safety 
campaigns (e.g. Clean Your Hands campaign) and antimicrobial resistance. 

Among  the  obstacles  reported,  Member  States  highlighted  that  collaboration  with  other 
countries  is  often  carried  out  at  expert  level,  without  being  officially  endorsed.  They  also 
mentioned  that  differences  between  healthcare  systems  and  language  barriers  hamper 
effective cooperation. 

1.7. 

Develop and promote research on patient safety 

Within  the  Seventh  Research  Framework  Programme,  the  EU  co-financed  the  following 
research projects related with patient safety:  

EN 

28 

   EN 

 
 
ORCAB:  Improving  quality  and  safety  in  the  hospital:  the  link  between  organisational 
culture,  burnout,  and  quality  of  care.  The  aim  of  the  present  project  is  to  benchmark  the 
organisational  and  individual  factors  that  impact  on  quality  of  care  and  patient  safety,  and 
design bottom-up interventions that both increase quality of care and physician well being. . 
On-going  project:  1  November  2009  –  30  April  2014.  EU  co-funding:  EUR  1  910  480. 
http://orcab.web.auth.gr/orcab/Index.html  

QUASER:  Quality  and  safety  in  European  Union  hospitals:  a  research-based  guide  for 
implementing best practice and a framework for assessing performance. The project aims to 
design and disseminate an evidence based guide for hospitals to implement quality and safety 
improvement programmes, and an evidence based framework for payers to assess and monitor 
the quality and safety of hospitals across the EU. On-going project: 1 April 2010 – 31 March 
2013. EU co-funding: EUR 2 999 842. http://www.kingspssq.org.uk/programmes/quality-and-
safety-in-european-union-hospitals  

DUQUE: Deepening our understanding of quality improvement in Europe. The objective is to 
study  the  effectiveness  of  quality  improvement  systems  in  European  hospitals.  Ongoing 
project:  1  November  2009  –  30  April  2013.  EU  co-funding:  EUR  2  996  189. 
http://www.duque.eu/  

LINNEAUS  EURO  –  PC:  Learning  from  international  networks  about  errors  and 
understanding  safety in primary care.  On-going project: 1 March 2009 – 28 February 2013. 
EU co-funding: EUR 2 461 250. http://www.linneaus-pc.eu/#  

HANDOVER:  Improving  the  continuity  of  patient  care  through  identification  and 
implementation  of  Novel  patient  handoff  processes  in  Europe.  The  overall  objective  was  to 
optimize  the  continuum  of  clinical  care  at  the  primary  care  hospital  interface  by  reducing 
unnecessary  and  avoidable  treatment  -  medical  errors  and  loss  of  life,  by  identifying  and 
studying best practices and creating standardized approaches to handoff communication at the 
primary care hospital interface and measuring the effectiveness of these practices in terms of 
costs and impact. Completed project: 1 October 2008 – 30 September 2011. EU co-funding: 
EUR 2 623 200. http://www.handover.eu/index.html  

level.  To 

tackle  performance  measurement 

ECHO: European Collaboration for Healthcare Optimization. It aims at describing the actual 
performance  of  six  different  Healthcare  Systems  at  hospital,  healthcare  area,  regional  and 
country 
two  different 
methodological approaches will be used: [a] a population geographical-based, responding the 
question: Is the access to a diagnostic or surgical procedure dependant on the place where a 
person lives? And, [b] a provider-specific, answering the question: Is the risk for a patient to 
access high quality care -and have better health outcomes- different regarding the provider in 
which  he  or  she  is  admitted?  On-going  project:  1  March  2012  –  31  August  2013.  EU  co-
funding: EUR 2 737 998. http://www.echo-health.eu/  

this  project, 

in 

Only  10  Member  States  (BE,  DE,  ES,  FR,  HU,  IE,  IT,  NL,  SE,  UK)  and  one  Region 
(Extremadura)  reported  they  had  national  research  programme  on  patient  safety.  Existing 
research covers patient safety culture, reducing the risk of medication errors, improvement of 
patients competence in medication safety, healthcare associated infections, prevention of falls 
in elderly population, impact of the absenteeism of healthcare workers on patient satisfaction, 
impact  of  teleradiology  on  vital  emergencies,  instruments  to  measure  adverse  events, 
frequency of adverse events at hospitalized patients. 

EN 

29 

   EN 

 
Regarding the obstacles, Member States reported that due to the financial constraints and to 
allocation  of  national  budgets,  their  research  projects  are  sometimes  not  supported  by  the 
governments. 

1.8. 

Summary of implementation progress  

Among  13  actions  envisaged  by  the  Recommendation  and  analysed  in  this  report,  the 
following  three  were  implemented  by  the  highest  number  of  countries:  embedding  patient 
safety  as  a  priority  issue  in  public  health  policies  (all  countries);  designating  a  competent 
authority  responsible  for  patient  safety  (25  countries);  and  encouraging  training  on  patient 
safety in healthcare settings (24 countries). The actions implemented by the lowest number of 
countries are: embedding patient safety in undergraduate and postgraduate education, on-the-
job  training  and  the  continuing  professional  education  of  health  professionals  (three 
countries); information to patients about patient safety (five countries); dissemination of core 
knowledge  on  patient  safety  to  health  professionals  (11  countries)  and  developing  core 
competencies  in  patient  safety  for  patients  (12  countries).  Figure  10  shows  the  levels  of 
implementation of particular actions as reported by countries.  

Figure 10: Summary of actions implemented by countries 

1b.PS as p riority in hea lth poli cies

1a.designa tio n o f co mp ete nt authority on  P S

4a.encour aging training  in hea lthcare  settin gs

1e.encour aging HP organisations ro have a  rol e in  PS

1c.d evelopment of safe r systems, proceses an d tools

1d.regu lar update of PS  sta ndard s or oth er me asu res

2a.involving patient organisations in policy making

1f.specific actions to promote the most common  ad ve rse events

3. e xistance o f fu lly ope rati onal RLSs

15

2c.core  competencies for patients on  PS

4c.d issemination  of core  knowled ge o n P S for HP

2b.information to  pa tien ts a bout p atie nt safe ty

4b.embed ding PS in education and training  at differen t levels

12

11

5

3

28

25

24

22

22

22

20

20

yes

no

0

10

20

30

Regarding  number  of  actions  implemented  by  countries,  the  following  groups  can  be 
distinguished: 

Table 6: Number of actions implemented by countries 

Countries having implemented all 13 actions  

0 countries 

Countries having implemented between 10 and 12 actions  9  countries:  CZ,  DE,  DK,  ES, 

FR, IE, IT, NL, UK 

Countries having implemented between 7 and 9 actions 

14  countries:  AT,  BE,  BG,  EE, 

EN 

30 

   EN 

 
 
Countries having implemented between 4 and 6 actions 

3 countries: CY, HU, LV 

Countries having implemented between 1 and 3 actions 

2 countries: EL, RO 

FI,  LT,  LU,  MT,  NO,  PL,  PT, 
SE, SI, SK 

EN 

31 

   EN 

 
 
2. 

PREVENTION AND CONTROL OF HEALTHCARE ASSOCIATED INFECTIONS 

2.1. 

Strategies, action plans, indicators and inter-sectoral mechanisms 

Discussion on main findings 

About  2/3  of  the  countries  had  defined  a  national  strategy  and/or  an  action  plan  for  the 
prevention and control of HAI in 2011. 

More  than  80%  of  national  action  plans  included  the  implementation  in  hospitals  of:  an 
infection  prevention  and  control  programme;  appropriate  organisational  governance 
arrangements and qualified infection control staff; surveillance of targeted HAI; surveillance 
of  particular  events  for  timely  detection  of  alert  microorganisms  or  HAI;  and  high  quality 
microbiological documentation and patient records. Fourteen countries out of seventeen with 
an action plan at the national level had set up mechanisms to encourage its implementation, 
often through the mandatory reporting of indicators. 

Fifteen  countries  had  considered  nursing  homes  and  healthcare  institutions  other  than 
acute care hospitals when designing their action plans. 

There  is  still  room  to  improve  information  to  patients  and  their  involvement  in  HAI 
prevention:  providing  information  to  the  patient  was  among  the  least  frequent  objectives  of 
action plans. In addition, patients’ representatives were part of the inter-sectoral mechanism in 
about 30% countries or regions only. 

In 2011, not all countries had set up a system of indicators to assess the implementation of 
the strategy/action plan, although the need for monitoring trends to adapt activities is largely 
admitted. As underlined by one respondent, the IPSE consensus on standards and indicators3 
and  current  European  projects  to  develop  a  suitable  system  to  collect  and  report  indicators, 
should  help  countries  and  regions  to  increase  their  ability  to  assess  their  situation  and  to 
compare  with  other  countries  when  relevant.  In  addition,  some  indicators  may  be  similar  to 
those  promoted  through  the  reinforcement  of  strategies  for  the  prudent  use  of  antimicrobial 
agents in human medicine and for patient safety. The fact that more than half of responding 
countries  reported  that  the  strategy  on  HAI  was  linked  to  the  strategy  for  prudent  use  of 
antimicrobial agents in human medicine and/or to the strategy for patient safety contributes to 
enhance consistency in the implementation and the assessment of public health policies. 

Public reporting of indicators on HAI prevention and control at the hospital level was in place 
in six countries. 

2.1.1. 

Strategies for the prevention and control of HAI 

The appropriate level for developing and enacting a strategy for the prevention and control 
of  healthcare  associated  infections  (HAI)  (see  Article  8  of  Council  Recommendation 
2009/C 151/01) was the national/federal level in 18 Member States. Nine countries reported 
that both the national and regional levels were appropriate. The appropriate level for the UK 
is the regional level. 

3 

Improving patient safety in Europe (IPSE). The IPSE consensus on standards and indicators. May 2008. 

EN 

32 

   EN 

 
                                                 
Eighteen countries (AT, BE, BG, DE, DK, EL, ES, FR, HU, IE, IT, LT, LU, NL, NO, PT, SE, 
SK) had a national strategy. England and Scotland had a regional strategy. 

A strategy had not yet been issued in nine Member States: 

• 

• 

Six had a national strategy under preparation (CY, CZ, EE, FI, PL, SI); 

Three had no national strategy (LV, MT, RO). 

All nine countries where both levels were appropriate to develop a strategy, also had regional 
strategies  (AT,  DE,  DK,  EL,  ES,  FR,  IT,  NO,  SE).  Regional  strategies  could  differ 
substantially from the national strategy in ES (in two out of five responding regions) and in IT 
(in two out of eight responding regions). 

Overall, 32 strategies had been defined in the 42 responding countries and regions. 

Seventeen countries and six regions provided a web link to access the strategy on the internet. 

The median year of first issue (17 countries provided data) and the median year of last update 
(14 countries) of the strategy were 2002 and 2009, respectively (Figure 11). 

Number of
 national strategies

5

4

3

2

1

date of first issue (N=17)

date of last update (N=14)

Median=2002

Median=2009

1990 

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001 2002

2003

2004

2005

2006

2007 2008 2009

2010

2011

and be-

f ore

Figure 11: Dates of first issue and last update of the strategy 

In 17 Member States (89%), and in 10 Spanish or Italian regions (77%), strategies were linked 
to another public health strategy: 

• 

• 

• 

4 

in 14 Member States (BE, BG, DE, DK, EL, FR, HU, IE, IT, LU, NL, PT, SE, UK4) 
and  four  regions  (Community  of  Madrid;  Autonomous  Province  of  Trento,  Emilia-
Romagna,  Liguria)  with  the  strategy  for  prudent  use  of  antimicrobial  agents  in 
human medicine; 

in  11  Member  States  (BG,  DE,  DK,  EL,  ES,  FR,  HU,  IT,  LU,  NL,  PT)  and  10 
regions  (Basque  Country,  Catalonia,  Ceuta  and  Melilla,  Community  of  Madrid; 
Apulia,  Autonomous  Province  of  Trento,  Emilia-Romagna,  Friuli-Venezia  Giulia, 
Piedmont; Scotland) with the strategy for patient safety; 

in five Member States (DE, DK, IT, LT, SK) and three regions (Ceuta and Melilla; 
Autonomous Province of Trento; Scotland) with other public health strategies: food 

Responded at regional level only. 

EN 

33 

   EN 

 
 
                                                 
safety  and  veterinarian  public  health,  immunisation  programme,  prevention  of 
communicable  diseases,  methicillin-resistant  Staphylococcus  aureus  (MRSA) 
prevention, biological risk in healthcare workers, industrial health and safety, health 
service quality strategy, strategies about chronic diseases. 

2.1.2.  Action plans 

The  action  plan  should  describe  what  actions  are  needed  at  the  national/regional  level  and 
which  institution(s)  should  lead  them  to  achieve  the  objectives  listed.  Action  plans  were 
available  in  18  countries  (AT,  BE,  BG,  CZ  (with  strategy  under  preparation),  DE,  DK,  EL, 
ES,  FR,  HU,  IE,  IT,  LT,  NL,  NO,  PT,  SK,  UK)  and  in  11  regions  (Andalusia,  Basque 
Country, Catalonia, Community of Madrid; Apulia, Autonomous Province of Trento, Emilia-
Romagna, Friuli-Venezia Giulia, Liguria, Lombardy, Piedmont). 

In  addition,  five  Member  States  had  an  action  plan  under  preparation:  two  Member  States 
with a national strategy (LU, SE) and three Member States with a national strategy also under 
preparation (EE, PL, SI). 

(t) 

Scope of the action plan 

In all 18 countries, action plans addressed acute care hospitals. In all but PT, other hospitals 
were  also  addressed.  In  all  but  three  Member  States  (AT,  HU,  PT),  some  objectives  of  the 
action plan also encompassed nursing homes. 

When information was available, the median year of first issue of the action plan was 2001 for 
acute care (nine countries provided data) and other hospitals (seven countries provided data) 
and  2006  for  nursing  homes  (two  countries  provided  data).  The  median  year  of  last  update 
was 2009 for acute care hospitals (eight countries provided data), 2010 for other hospitals (six 
countries provided data) and 2011 for nursing homes (two countries provided data). 

(u) 

Objectives of the action plan 

The objectives of the action plan, at the national/regional level and at the level of healthcare 
institution, in reference to the Recommendation, were described (Table 7). For each objective, 
it  was  specified  whether  acute  care  hospitals,  other  hospitals  and/or  nursing  homes  were 
addressed. Information on the action plan was available from 17 countries (AT, BE, BG, CZ, 
DE, DK, EL, ES, FR, HU, IE, IT, LT, NL, NO, PT, SK) and 13 regions (Andalusia, Basque 
Country, Catalonia, Community of Madrid; Apulia, Autonomous Province of Trento, Emilia-
Romagna, Friuli-Venezia Giulia, Liguria, Lombardy, Piedmont; England, Scotland). 

At  the  national  level,  the  two  most  widespread  objectives,  for  the  three  types  of  healthcare 
institutions  were  the  implementation  of  standard  infection  prevention  and  control  measures 
and the provision of guidelines. 

In  national  action  plans,  the  third  most  common  objective  for  acute  care  hospitals  was  the 
surveillance of incidence of targeted types of infections of HAI to establish national reference 
data. The third and fourth most common objective for other hospitals was the timely detection 
and reporting of alert healthcare associated organisms or clusters of HAI to the relevant body, 
and  education  on  the  prevention  and  control  of  HAI  for  healthcare  workers  (other  than 
infection control staff). For nursing homes the third and fourth most common objectives were 
the  implementation  of  risk-based  infection  prevention  and  control  measures  and  the 
performance of prevalence surveys of HAI at regular intervals. 

EN 

34 

   EN 

 
At  the  regional  level,  the  most  widespread  objectives  were:  the  provision  of  guidelines,  the 
implementation  of  standard  and  risk-based  infection  prevention  and  control  measures,  the 
definition  and  implementation  of  specialised  infection  control  training  and/or  education 
programmes  for  infection  control  staff,  and  the  education  on  the  prevention  and  control  of 
HAI for healthcare workers other than infection control staff. 

Among the least common objectives were: 

• 

• 

in national and regional action plans, the promotion of adherence to prevention and 
control  measures  by  using  the  results  of  accreditation  or  certification  processes  in 
place and the surveillance of process and structure indicators to evaluate the strategy; 

in national action plans: 

– 

in acute care hospitals, the promotion of consistency in, and communication of, 
infection  prevention  and  control  measures  between  healthcare  providers 
treating  or  caring  for  a  particular  patient,  e.g.  actions  at  the  national/regional 
level to promote the development of shared patient files or liaison documents 
to ensure that appropriate infection control measures are applied to the patient 
when transferred to another healthcare institution or when discharged; 

– 

in  other  hospitals  and  nursing  homes,  the  use  of  structure  and  process 
indicators to promote adherence to prevention and control measures. 

In  ES,  the  objectives  at  the  level  of  the  healthcare  institutions  were  addressed  only  in  the 
regional action plans and not in the national action plan. 

At the level of healthcare institutions, in national and regional action plans, the most frequent 
objectives for all types of healthcare institutions were to have in place: 

• 

• 

• 

• 

surveillance  of  particular  infection  types  and/or  particular  strains  of  healthcare-
associated  pathogens  for  the  timely  detection  of  alert  healthcare-associated 
organisms or clusters of HAI; 

an  infection  prevention  and  control  programme  addressing  organisational  and 
structural  arrangements,  diagnostic  and  therapeutic  procedures  (for  example 
antimicrobial  stewardship),  resource  requirements,  surveillance  objectives,  training 
of healthcare personnel; 

appropriate  organisational  governance  arrangements  for  the  elaboration  and  the 
monitoring of the IC programme 

appropriate  organisational  arrangements  and  qualified  personnel  with  the  task  of 
implementing the infection prevention and control programme. 

The least common objectives dealt with general information to the patient: making available 
objective  and  understandable  information  about  the  risk  of  HAI,  about  the  measures 
implemented  by  the  healthcare  institution  to  prevent  them  and  on  how  patients  can  help  to 
prevent  those  infections;  the  infection  prevention  and  control  programme  rarely  included 
provision of information to patients on HAI. 

EN 

35 

   EN 

 
In  addition,  consistent  with  the  scarcity  of  action  plans  including  this  objective  at  the 
national/regional level, only two regional action plans for nursing homes aimed at having in 
place  process  and  structure  indicators  to  evaluate  the  implementation  of  infection  control 
measures (Apulia and Emilia-Romagna). 

Table 7: Objectives and scope of the action plan in 17 countries and 13 regions with action plan 

Objectives 

National or regional level6 

Countries (N= 17) 

Regions (N=13)5 

Acute 
care 
hospi-
tals 

Other 
hospi-
tals 

Nur-
sing 
ho-
mes 

Acute 
care 
hospi-
tals 

Other 
hospi-
tals 

Nur-
sing 
ho-
mes 

Provision of guidelines and recommendations  

Implementation  of  standard  prevention  and 
control measures in healthcare settings 

16 

17 

13 

14 

10 

10 

13 

11 

Implementation 
prevention  and  control  measures 
healthcare settings 

risk-based 

of 

infection 
in  all 

13 

11 

7 

12 

7 

9 

9 

6 

4 

4 

of 

consistency 

Promotion 
and 
communication  of,  infection  prevention  and 
control measures between healthcare providers 
treating or caring for a particular patient7 

in, 

11 

9 

5 

4 

3 

3 

Promotion  of  adherence  to  prevention  and 
control  measures  by  using  structure  and 
process indicators 

14 

8 

Promotion  of  adherence  to  prevention  and 
control  measures  by  using  the  results  of 
accreditation or certification processes in place 
Prevalence surveys of HAI at regular intervals 

Surveillance  of  incidence  of  targeted  types  of 
HAI  to  establish  national/regional  reference 
data 
Process and structure indicators to evaluate the 
strategy 

10 

12 

15 

13 

8 

7 

8 

8 

3 

2 

7 

3 

0 

9 

7 

8 

10 

6 

3 

3 

4 

3 

4 

2 

3 

3 

2 

3 

5 
6 

7 

Including England and Scotland. 
The  action  plan  should  describe  what  actions  are  needed  at  the  national/regional  level  and  which 
institution(s) should lead them to achieve the objectives listed. 
E.g. actions at the national/regional level to promote the development of shared patient files or liaison 
documents  to  ensure  that  appropriate  infection  control  measures  are  applied  to  the  patient  when 
transferred to another healthcare institution or when discharged. 

EN 

36 

   EN 

 
 
 
 
 
 
                                                 
Objectives 

Countries (N= 17) 

Regions (N=13)5 

Acute 
care 
hospi-
tals 

Other 
hospi-
tals 

Nur-
sing 
ho-
mes 

Acute 
care 
hospi-
tals 

Other 
hospi-
tals 

Nur-
sing 
ho-
mes 

Timely  detection  and 
reporting  of  alert 
healthcare  associated  organisms  or  clusters  of 
HAI to the relevant body 

13 

12 

Definition  and  implementation  of  specialised 
infection  control  training  and/or  education 
programmes for infection control staff 

14 

11 

6 

4 

10 

12 

6 

6 

Education  on  the  prevention  and  control  of 
than 
for  healthcare  workers  other 
HAI 
infection control staff 

13 

12 

6 

11 

6 

3 

4 

3 

Reporting  of  clusters  and  infection  types  of 
relevance  for  the  Community  or  international 
level 
Support  of 
fields  such  as 
epidemiology  of  HAI,  new  preventive  and 
therapeutic 
interventions, 
cost-effectiveness  of  infection  prevention  and 
control 

technologies  and 

research 

in 

Level of healthcare institutions8 

Having  in  place  an  infection  prevention  and 
control  programme  addressing  organisational 
and  structural  arrangements,  diagnostic  and 
example 
therapeutic 
resource 
antimicrobial 
requirements,  surveillance  objectives,  training 
of healthcare personnel  

stewardship), 

procedures 

(for 

13 

9 

6 

6 

15 

11 

5 

11 

7 

2 

Having  in  place  an  infection  prevention  and 
control  programme  addressing  information  to 
patients on HAI 

Having  in  place  appropriate  organisational 
governance  arrangements  for  the  elaboration 
and the monitoring of the infection prevention 
and control programme9 

6 

4 

2 

7 

4 

1 

14 

11 

6 

9 

5 

1 

8 

9 

The  action  plan  should describe  what  actions  are needed at  the  healthcare  institution  level  and, when 
relevant, who should lead them to achieve the objectives listed. 
E.g. infection prevention and control committee or equivalent multidisciplinary system. 

EN 

37 

   EN 

 
 
 
 
 
 
                                                 
Objectives 

Countries (N= 17) 

Regions (N=13)5 

Acute 
care 
hospi-
tals 

Other 
hospi-
tals 

Nur-
sing 
ho-
mes 

Acute 
care 
hospi-
tals 

Other 
hospi-
tals 

Nur-
sing 
ho-
mes 

Having  in  place  appropriate  organisational 
arrangements  and  qualified  personnel  with  the 
task  of  implementing  the  infection  prevention 
and control programme 

14 

12 

4 

11 

7 

Encouraging  high  quality  microbiological 
documentation10 and patient records11 

14 

11 

4 

5 

3 

8 

6 

10 

5 

3 

3 

10 

14 

5 

8 

2 

2 

1 

1 

Performing  prevalence  surveys  at  regular 
intervals 

Surveillance  of 
infection types 

the 

incidence  of 

targeted 

types 
infection 
Surveillance  of  particular 
and/or  particular 
strains  of  healthcare-
associated  pathogens  for  the  timely  detection 
of  alert  healthcare-associated  organisms  or 
clusters of HAI  

15 

13 

5 

10 

6 

1 

Process and structure indicators to evaluate the 
implementation of infection control measures 

10 

7 

Provision  of  regular  training  for  all  healthcare 
personnel,  on  basic  principles  of  hygiene  and 
infection prevention and control 

13 

11 

Provision  of  regular  advanced  training  for 
personnel having particular tasks related to the 
prevention and control of HAI  

12 

9 

Information  to  the  patients:  making  available 
information 
objective  and  understandable 
about the risk of HAI 

7 

5 

0 

4 

3 

1 

8 

9 

9 

5 

5 

5 

5 

2 

2 

2 

1 

2 

the  measures 

Information  to  the  patients:  making  available 
information 
objective  and  understandable 
about 
the 
healthcare  institution  to  prevent  them  and  on 
how  patients  can  help 
those 
infections  

implemented  by 

to  prevent 

6 

4 

0 

6 

3 

1 

10 

11 

E.g.  encouraging  to  have  timely  access  to  microbiological  analysis,  including  antimicrobial 
susceptibility testing, external quality control. 
E.g. computerised medical records. 

EN 

38 

   EN 

 
 
 
                                                 
Objectives 

Information  to  the  patients:  providing  specific 
information,  for  example  on  prevention  and 
control  measures,  to  patients  colonised  or 
infected with healthcare-associated pathogen 

Countries (N= 17) 

Regions (N=13)5 

Acute 
care 
hospi-
tals 

Other 
hospi-
tals 

Nur-
sing 
ho-
mes 

Acute 
care 
hospi-
tals 

Other 
hospi-
tals 

Nur-
sing 
ho-
mes 

9 

8 

3 

7 

4 

2 

(v) 

Mechanisms to encourage the implementation of actions 

Mechanisms  to  encourage  the  implementation  of  actions  for  prevention  and  control  of  HAI 
were reported by 14 out of 17 countries (82%) with an action plan (BE, BG, DE, DK, EL, ES, 
FR, HU, IE, LT, NL, NO, PT, SK). In IT, there was no mechanism at the national level, but 
some  were  reported  at  the  regional  level.  In  addition,  it  was  planned  to  develop  such 
mechanisms  in  five  countries  of  which  three  had  a  national  action  plan.  Among  13  regions 
with  action  plan,  nine  (70%)  had  such  mechanism  (Andalusia,  Basque  Country,  Catalonia, 
Community  of  Madrid;  Autonomous  Province  of  Trento,  Emilia-Romagna,  Friuli-Venezia 
Giulia, Piedmont; Scotland). These mechanisms to encourage the implementation of actions 
were: 

• 

• 

• 

• 

• 

• 

mandatory  reporting  of  indicators  (structure,  process,  outcomes)  in  eight  countries 
(BE, BG, DK, EL, FR, IE, NO, SK) and eight regions (Andalusia, Basque Country, 
Catalonia,  Community  of  Madrid;  Autonomous  Province  of  Trento,  Friuli-Venezia 
Giulia, Piedmont; Scotland); 

inclusion in certification or accreditation process in seven Member States (BG, DE, 
DK, FR, LT, NL, PT) and four regions (Andalusia; Autonomous Province of Trento, 
Emilia-Romagna, Piedmont); 

binding regulation in nine countries (BE, BG, DE, DK, FR, HU, LT, NO, SK) and 
Community of Madrid 

financial  sanctions  in  five  Member  States  (BG,  DE,  FR,  LT,  SK)  and  two  regions 
(Emilia-Romagna, Friuli-Venezia Giulia); 

financial  incentives  in  two  Member  States  (BE,  PT)  and  three  regions  (Andalusia, 
Catalonia, Community of Madrid); 

others  (inspection  by  health  authorities,  by  independent  bodies,  self-assessment, 
budget  for  regions)  in  two  Member  States  (DE,  ES)  and  two  regions  (Basque 
Country; Scotland). 

EN 

39 

   EN 

 
 
 
 
(w) 

Financial resources 

Dedicated budgets for implementation of the action plan were identified in nine countries and 
three  regions.  A  budget  was  allocated  by  the  Government  annually  in  seven  countries  (BE, 
EL,  ES,  FR,  IT,  LU,  NO),  and  occasionally  in  two  Member  States  (DE,  HU).  In  addition, 
regional annual budgets existed in ES and NO, in Emilia-Romagna and in Scotland. Regional 
occasional budget could be dedicated in DE. In addition to the annual budget, the Government 
could assign occasional budget in BE, FR, and LU. 

Examples  of  activities  funded  in  2009-2010  were  reported  by  13  respondents  from  nine 
countries. The most commonly funded activities related to campaigns and actions to improve 
hand hygiene: 10 out of 13 respondents in six Member States (BE, EL, ES, FR, HU, PT) and 
four regions (Andalusia; Autonomous Province of Trento, Piedmont; Scotland). Other funded 
projects  dealt  with  surveillance  projects,  prevention  activities,  reinforcement  of  human 
resources, education and evaluation: 

• 

• 

• 

• 

• 

• 

• 

development of information technology support for surveillance (4); 

development  of  surveillance  of  bacteraemia, point  prevalence  surveys  in  acute  care 
hospitals and nursing homes (3); 

elaboration and dissemination of guidelines for the prevention of HAI,  for  instance 
infections associated to surgery (2), blood stream infections (2), ventilator-associated 
pneumonia,  catheter  related  urinary  tract  infections,  device-related  infections, 
isolation measures (one each); 

implementation/reinforcement  of  infection  control  or  antimicrobial  staff  (3): 
infection control teams, infection control managers, antimicrobial pharmacists; 

education and training courses (2), management of networks of professionals (2); 

evaluation  (visits  of  hospitals  by  an  expert  advisory  team  to  assess  prevention  and 
management of HAI outbreaks, assessment of a national network surveillance); 

experimental  study  (methods  for  the  control  of  Legionella  in  hot  water  supply 
system). 

2.1.3. 

Indicators 

(x) 

Indicators to assess the implementation of the strategy or action plan 

Seventeen countries (AT, BE, BG, DK, EL, ES, FR, IE, IT, MT, LT, LU, NL, NO, PT, SK, 
UK)  and  nine  regions  (Andalusia,  Catalonia,  Community  of  Madrid;  Apulia,  Autonomous 
Province  of  Trento,  Emilia-Romagna,  Friuli-Venezia  Giulia,  Liguria,  Piedmont)  stated  they 
had indicators to assess the implementation of the strategy or the action plan. In addition, six 
Member States (CZ, DE, HU, PL, SE, SI) and Basque Country reported being in the process 
of developing indicators of which SI had a strategy and an action plan under preparation. MT 
had indicators despite having neither strategy nor action plan. 

The  most  frequently  used  indicator  in  all  types  of  healthcare  institutions,  in  14  out  of  16 
countries,  and  9  out  of  11  regions  was  a  process  indicator  referring  to  the  organisation  of 
campaigns to improve hand hygiene (Table 8). Another process  indicator  was  often used in 

EN 

40 

   EN 

 
other  hospitals  and  nursing  homes:  volume  of  alcohol  hand  rub  products  for  hand  hygiene. 
Outcome  indicators  were  mainly  used  in  acute  care  hospitals:  results  from  surveillance  of 
surgical  site  infections,  infections  in  ICU,  prevalence  surveys.  Most  common  outcome 
indicators in other hospitals and nursing homes were: results of point-prevalence surveys and 
MRSA incidence. 

Among  indicators  listed  in  the  questionnaire,  the  number  of  single  rooms  was  monitored  in 
five countries (BG, DK, EL, NO, ES). 

Table 8: Number of countries and of regions using indicators to assess the implementation of the strategy 
or action plan in place according to the type of healthcare institution 

Number of countries (N=16) 

Number of regions (N=11) 

Acute 
care 
hospi-
tals 

Other 
hospi-
tals 

Nursing 
homes 

Acute 
care 
hospi-
tals 

Other 
hospi-
tals 

Nursing 
homes 

Name of indicator 

Structure indicators 

Human  resources:  number  of  full  time 
equivalent  (FTE)  infection  control  staff 
per  1000  beds  or  per  hospital 
(denominator used in MT and SK) 

Number  of  single  rooms  (unit:  per 
ward, specified by BG) 

Annual  report  on  implementation  of 
infection control programme  

Process indicators 

Volume  of  alcohol  hand  rub  products 
used per year. 

Measurement unit: ml or litres / patient-
days (or occupied bed days or days of 
hospitalisation)  

12 

10 

5 

10 

3 

6 

12 

7 

Campaign to improve hand hygiene 

14 

11 

Outcome indicators 

Incidence 
of 
Staphylococcus aureus (MRSA)  

meticillin-resistant 

Incidence  of  extended-spectrum  beta-
lactamase 
(ESBL)-producing 
Enterobacteriaceae 

11 

8 

6 

4 

1 

0 

1 

3 

8 

2 

1 

2 

0 

7 

5 

9 

7 

4 

1 

0 

3 

2 

4 

2 

2 

0 

0 

2 

1 

2 

2 

2 

EN 

41 

   EN 

 
 
 
 
 
 
 
 
 
 
 
 
Name of indicator 

Number of countries (N=16) 

Number of regions (N=11) 

Acute 
care 
hospi-
tals 

Other 
hospi-
tals 

Nursing 
homes 

Acute 
care 
hospi-
tals 

Other 
hospi-
tals 

Nursing 
homes 

Incidence  of  other  multidrug-resistant 
microorganisms (MDR)12 
Incidence  of  surgical  site  infections  (at 
least some procedures) 

Incidence  of  some  or  all  infections  in 
intensive care units 

Results  of  point  prevalence  surveys 
(PPS) 

9 

13 

13 

11 

5 

4 

3 

5 

2 

- 

- 

3 

3 

8 

6 

7 

2 

2 

1 

3 

1 

Responding  countries/regions  could  monitor  indicators  other  than  those  listed  in  the 
questionnaire: 

• 

Structure indicators: proportion of beds with alcohol hand rub products at the point 
of care; proportion of beds with alcohol hand rub products in the room; proportion of 
hospitals  with  information  system  for  the  laboratory;  composite  indicator  on  HAI 
organisation, activities and resources; 

• 

Process indicators: 

– 

– 

– 

– 

– 

related to hand hygiene (hand hygiene compliance, compliance to WHO hand 
hygiene  recommendations,  proportion  of  hospitals  (or  primary  care  areas) 
receiving  basic  training  in  hand  hygiene,  proportion  of  hospitals  receiving 
training  in  the  WHO  Five  Moments  for  Hand  Hygiene13,  proportion  of 
hospitals  using  WHO  observational  tools,  proportion  of  hospitals  reporting 
self-evaluation with WHO tools); 

related  to  surveillance  process  (proportion  of  hospitals  assessing  HAI 
prevalence, HAI incidence, participation in surveillance activities, participation 
in  national  patient  safety  programme,  proportion  of  hospitals  having  an  alert 
system for selected microorganisms); 

isolation procedures and measures; 

antibiotic  prescribing,  antibiotic 
surveillance, composite indicator assessing antibiotic stewardship; 

stewardship,  antibiotic  consumption 

environmental cleaning; endoscope reprocessing. 

12 

13 

all MDR, carbapenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii, Acinetobacter spp, 
Klebsiella spp, Pseudomonas spp; vancomycin-resistant Enterococci (VRE); resistance in Enterobacter 
cloacae, Citrobacter spp., Serratia marcescens resistant to carbapenems, ciprofloxacin and amikacin; P. 
aeruginosa and A. baumannii resistant to ciprofloxacin, amikacin, ceftazidim, piperacillin/tazobactam; 
Stenotrophomonas maltophilia. 
http://www.who.int/gpsc/tools/Five_moments/en/ 

EN 

42 

   EN 

 
 
 
 
 
 
 
                                                 
• 

Outcome indicators: MRSA prevalence in ICU, Staphylococcus aureus bacteraemia, 
MRSA  in  blood  culture,  Clostridium  difficile  infection,  blood  and  body  fluids 
exposures,  immunisation  coverage  of  healthcare  workers  against  Hepatitis  B  virus 
(HBV),  chickenpox  (varicella-zoster  virus,  VZV),  flu;  quantitative  reduction  in 
antibiotic consumption. 

(y) 

Public indicators at hospital level 

Six countries and two regions reported that indicators were publicly available at the hospital 
level: 

• 

• 

• 

• 

• 

• 

• 

• 

In  DK, 
(http://www.sundhedskvalitet.dk/noegletal.aspx); 

information  on 

surgical 

site 

infections  are  publicly  available 

FR  reported  six  indicators:  ICALIN  (aggregated  healthcare  infections  activities 
dashboard);  ICSHA  (alcohol  hand  rub  consumption  indicator);  SURVISO  (surgical 
site  infection  surveillance  indicator;  ICATB  (antibiotic  stewardship  indicator); 
MRSA  incidence  (http://www.icalin.sante.gouv.fr)  and  an  aggregated  indicator 
(“score agrégé”) combining the first four; 

In  IE,  three  indicators  were  available  at  hospital  level:  alcohol  hand  rub 
consumption,  Staphylococcus  aureus  bacteraemia  (EARS-Net)  and  hospital 
antibiotic consumption; 

LU reported the number of full time equivalent infection control staff; 

In MT, public indicators (for the main hospital) were: alcohol hand rub consumption, 
hand  hygiene  compliance,  hand  hygiene  campaign,  MRSA  and  Enterobacteriacae 
producing  extended-spectrum  betalactamase  (ESBL),  blood  and  body  fluids 
exposures, immunisation of healthcare workers; 

In  NO,  outcomes  results  were  publicly  available:  prevalence  of  urinary  tract 
infections, lower respiratory tract infections, surgical site infections and septicaemia 
(http://www.frittsykehusvalg.no/Kvalitet/Forklaring-kvalitetsindikatorer/Fysisk-
helse/Sykehusshyinfeksjoner/); 

In  Scotland,  all  indicators  are  displayed  at  hospital  level:  Clostridium  difficile 
infection,  methicillin-sensitive  Staphylococcus  aureus  (MSSA)  bacteraemia  cases 
and MRSA bacteraemia cases, hand hygiene compliance, cleaning compliance; 

In Piedmont, structure indicators and some process indicators (without specification) 
were reported to be publicly disclosed. 

(z) 

Indicators linked with financial incentives 

In one country and four regions, indicators could be linked with financial incentives: 

• 

In  LU,  financial  incentives  were  in  place  for  hospitals  with  intensive  care  units 
monitoring HAI in these units and for hospitals performing surveillance of incidence 
of selected multidrug resistant microorganisms; 

EN 

43 

   EN 

 
• 

• 

• 

In  the  Community  of  Madrid,  the  campaign  for  hand  hygiene  was  linked  with 
financial incentives; 

In  Italian  regions,  financial  incentives  were  reported  for  annual  reports  on  HAI 
prevention  and  control  in  Friuli-Venezia  Giulia  and  for  structure  and  process 
indicators in Emilia-Romagna; 

In England, the National Health Service (NHS) standard contracts for acute hospital, 
mental  health,  community  and  ambulance  services  set  financial  penalties  if  the 
number  of  Clostridium  difficile  infections  is  higher  than  expected  according  to  the 
terms of the contract. 

2.1.4. 

Inter-sectoral mechanisms or equivalent systems 

(aa) 

Scope of the inter-sectoral mechanisms or equivalent systems 

For the coordinated implementation of the national/regional strategy, 11 countries (BE, BG, 
CZ, DE, ES, HU, IT, LU, NL, NO, SK) and six regions (Andalusia, Catalonia; Autonomous 
Province  of  Trento,  Emilia-Romagna,  Friuli-Venezia  Giulia;  England)  had  an  inter-sectoral 
mechanism and five Member States (AT, DK, EL, LT, PL) and five regions (Community of 
Madrid;  Apulia,  Liguria,  Piedmont;  Scotland)  had  an  equivalent  system,  consisting  of  a 
committee or a unit/department in the ministry or a public health institution. 

Seven Member States (CY, EE, FI, FR, IE, MT, SE) and one region (Ceuta and Melilla) were 
in  the  process  of  setting  up  an  inter-sectoral  mechanism  and  gave  information  on  the 
scheduled date of its implementation and/or on its organisation. Four Member States (LV, PT, 
RO, SI), and two regions (Basque Country; Aosta Valley) had no inter-sectoral mechanism. 

Among 16 national and 11 regional (27) inter-sectoral mechanisms or equivalent mechanisms, 
12  national  (AT,  BE,  BG,  CZ,  DE,  EL,  ES,  HU,  IT,  LU,  NO,  PL)  and  nine  regional 
(Andalusia,  Catalonia;  Apulia,  Autonomous  Province  of  Trento,  Emilia-Romagna,  Friuli-
Venezia Giulia, Liguria; England, Scotland) were also in charge of coordinating the strategy 
for prudent use of antimicrobial agents in human medicine. 

The 16 national and 11 regional inter-sectoral mechanisms or equivalent mechanisms always 
covered acute care hospitals. In all countries and in all but four regions (Andalusia; Apulia, 
Friuli-Venezia  Giulia,  Lombardy),  the  inter-sectoral  mechanism  addressed  other  hospitals. 
Nursing homes were also included in the scope of the inter-sectoral mechanism in 11 Member 
States (BE, BG, CZ, DE, DK, ES, FR, IT, NL, PL, SE) and seven regions (Catalonia; Apulia, 
Emilia-Romagna,  Friuli-Venezia  Giulia,  Piedmont;  England,  Scotland).  The  scope  of  six 
inter-sectoral  mechanisms  in  four  Member  States  and  two  regions  also  included  other 
institutions than hospitals and nursing homes: 

• 

• 

primary/ambulatory  care,  including  general  practice,  general  dental  practice, 
domiciliary care (FR, DE, PL, ES, Friuli-Venezia Giulia, Scotland);  

childbearing (DE). 

(bb) 

Legal basis of the inter-sectoral mechanisms or equivalent systems 

Inter-sectoral mechanisms or equivalent systems had been established by regulation in 12 out 
of 16 countries (BE, BG, CZ, DE, EL, ES, HU, IT, LT, NO, PL, SK) and 6 out of 11 regions 

EN 

44 

   EN 

 
(Apulia, Autonomous Province of Trento, Emilia-Romagna, Friuli-Venezia Giulia, Piedmont; 
Scotland);  three  (DE,  SK  and  Scotland)  had  other  official  documents  in  addition.  Non-
regulatory official documents  constituted the  legal  basis of  the  inter-sectoral  mechanisms in 
two  Member  States  (official  mandate  in  DK,  ministerial  decision  in  LU)  and  one  region 
(patient  safety  project  for  Catalonia).  In  two  Member  States  (AT,  NL)  and  three  regions 
(Community of Madrid; Liguria; England), inter-sectoral mechanisms or equivalent systems 
had no official basis. Among eight inter-sectoral mechanisms under preparation, one was in 
the process of being established by regulation (FR, updated regulation issued mid-June 2011). 

The date of the regulation was specified by 10 countries (BG, CZ, EL, ES, FR, HU, IT, LT, 
NO,  PL)  having  such  legal  basis  in  place  or  under  preparation:  the  median  date  was  2009 
(first  in  1992,  last  in  2010).  This  date  may  be,  in  some  countries,  the  date  when  the  inter-
sectoral mechanism was updated (for instance, in FR), and not the date of first establishment. 

(cc) 

Governance of the inter-sectoral mechanisms or equivalent systems 

The 16 countries (AT, BE, BG, CZ, DE, DK, EL, ES, HU, IT, LT, LU, NL, NO, PL, SK) and 
10  regions  out  of  11  (Catalonia,  Community  of  Madrid;  Apulia,  Autonomous  Province  of 
Trento, Emilia-Romagna, Friuli-Venezia Giulia, Liguria, Piedmont; England, Scotland) with 
an inter-sectoral mechanism or equivalent system in place , and one Member State where the 
inter-sectoral mechanism was under preparation (FR  (updated  inter-sectoral mechanism was 
established mid-June 2011)) described the composition of their inter-sectoral mechanism (see 
Figure  12).  The  Ministry  of  Health  was  represented  in  inter-sectoral  mechanisms  in  all 
countries. Patients groups participated in the inter-sectoral mechanism in five Member States 
(BE,  CZ,  FR,  NL,  SK)  and  in  three  regions  (Catalonia;  England,  Scotland).  The  nursing 
homes sector was involved in three Member States (CZ, DK, FR) and five regions (Catalonia; 
Apulia, Emilia-Romagna, Friuli-Venezia Giulia; Scotland). 

The frequency of the meetings of the inter-sectoral mechanism was available for 10 Member 
States (AT, BG, CZ, DK, EL, ES, FR, HU, IT, PL) and nine regions (Community of Madrid; 
Apulia,  Autonomous  Province  of  Trento,  Emilia-Romagna,  Friuli-Venezia  Giulia,  Liguria, 
Piedmont;  England,  Scotland):  the  median  number  of  meeting  was  four  a  year  for  national 
inter-sectoral mechanisms (maximum: 12 in EL and ES, minimum: 1 to 2 per year in AT, DK 
and  PL)  and  four  a  year  for  regional  inter-sectoral  mechanisms.  In  LT,  the  inter-sectoral 
mechanism  had  held  no  meeting  in  2010.  There  were  minutes  of  each  meeting  of  the  inter-
sectoral mechanism in 14 countries (AT, BE, BG, CZ, DE, DK, EL, ES, HU, IT, LU, NO, PL, 
UK)  and  in  5  regions  (Community  of  Madrid;  Autonomous  Province  of  Trento,  Emilia-
Romagna,  Friuli-Venezia  Giulia,  Piedmont).  A  periodic  report  was  publicly  available  in  six 
Member States (DE, DK, EL, ES, FR, UK) and two regions (Apulia, Liguria), and had been 
last issued between 2009 and 2011 (web link provided by three Member States (FR, DE and 
EL) and by England). 

In  six  Member  States  (BE,  CZ,  EL,  ES,  HU,  IT),  the  inter-sectoral  mechanism  had  the 
mandate to cooperate with the Commission and the other Member States. 

EN 

45 

   EN 

 
Ministry of Health

Institute of epidemiology /HAI surveillance

Medical specialists

Reference laboratories

ICM for prudent use of antimicrobial agents

Professional societies

Hospital, public sector

Patient Safety competent body

Medicines agency

Pharmacists

Ambulatory sector/primary care

Medical devices agency

Health insurance

Nurses

Patient groups

Ministry in charge of elderly

Hospital, private sector

Ministry of employment

Ministry of education

Nursing homes

Veterinary, Food safety sector

Ministry of research

Regional health authorities representatives

4

4

3

3

3

3

3

3

3

3

3

5

5

5

5

1

1

2

1

17

16

14

12

12

12

10

9

9

9

7

7

7

7

6

6

6

6

6

8

8

8

ICM at national level (N=17)

ICM at regional level (N=10)

0

2

4

6

8

10

12

14

16

Number of ICM or equivalent system for HAI

Figure 12: Composition of inter-sectoral mechanism at the national level (N=17 countries) and at the 
regional level (N= 10 regions) 

2.2. 

Prevention  and  control  measures  at  national  or  regional  level  to  support  the 
containment of healthcare associated infections 

Discussion on main findings 

The most widespread guidelines and activities reported by countries and regions in 2011 were 
related to hand hygiene. This is not surprising, since hand hygiene is generally recognised as 
the most efficient way to prevent HAI. In addition, the World Alliance for Patient Safety, led 
by WHO, and the launch of an annual campaign for hand hygiene in 2008 (5 May) may also 
have helped countries to implement a wide range of activities in this area, as suggested by the 
high  level  of  use  of  WHO  tools.  Campaigns  and  actions  to  improve  hand  hygiene  were  the 
most frequent examples of activities funded in 2009-2010 (spontaneously reported by 10/13 
respondents  in  6  countries).  Guidelines  addressing  prevention  of  HAI  in  general  and 
prevention  of  main  HAI  (surgical  site  infections  and  catheter-related  bloodstream  infections 
prevention  in  hospitals  and  MRSA  and  catheter-related  urinary  tract  infections  in  nursing 
homes)  were  issued  in  most  countries.  Compared  to  2008,  more  countries  reported  having 
guidelines for prevention of HAI and MDRB in general in hospitals (20 for HAI and 13 for 
MDRB in 2011, compared to 17 and 10 respectively in 2008) and in nursing homes (13 and 7 

EN 

46 

   EN 

 
 
versus  9  and  4  respectively)  and  for  prevention  and  control  of  MRSA  and  C.  difficile 
infections  in  nursing  homes  (16  for  MRSA  and  14  for  C.  difficile,  compared  to  11  and  6 
respectively in 2008)14. 

Nineteen  countries  had  considered  nursing  homes  and  institutions  other  than  acute  care 
hospitals  when  disseminating  guidelines.  Even  if  some  respondents  stated  that  guidelines 
designed for hospitals may apply, to a certain extent, to other healthcare institutions, it seems 
useful  to  tailor  their  practical  implementation  to  resources  and  needs  of  institutions  like 
nursing  homes  and  long-term  care,  namely  regarding  acute  gastro-enteritis  and  respiratory 
tract  infections.  Results  from  the  HALT  survey15  and  other  European  projects  may  help 
professionals to design such guidelines. 

Countries  without  guidelines  could  benefit  from  experience  of  other  countries,  for  instance 
through the network of national focal points for HAI set up under the auspices of ECDC. 

Guidelines for hand hygiene were available in 22 countries (BE, BG, CY, CZ, DE, DK, EL, 
ES, FI, FR, HU, IE, IT, LT, LU, MT, NL, NO, PT, SE, SI, UK) and all but three (IE, FI, SE) 
referred  to  WHO  guidelines.  In  addition,  three  Member  States  had  guidelines  under 
preparation (AT, PL, SK) and LV had regulatory requirements about hand hygiene. EE and 
RO  had  no  guidelines  for  hand  hygiene.  Guidelines  were  available  in  all  regions  except 
Liguria and referred to WHO guidelines. 

Healthcare  workers  compliance  to  the  guidelines  for  hand  hygiene  had  been  assessed  in  18 
countries (AT, BE, BG, CY, DE, DK, EL, ES, FR, HU, IT, LU, MT, NO, PL, PT, SE, UK), of 
which  15  made  use  of  WHO  tools.  In  addition,  five  Member  States  were  in  the  process  of 
assessing compliance: CZ, EE (although no guidelines were available), IE, NL, SK. Among 
the 13 Spanish and Italian regions, 10 had assessed compliance to the guidelines making use 
of WHO tools. 

Hand hygiene campaigns had been carried out in 18 countries and were under preparation in 
four (AT, EE, PL, SI). WHO tools had been used in all but three: DK, NO, SE. Among the 13 
Spanish and Italian regions, 12 had carried out campaigns and 11 had used WHO tools. 

At the national level, the last campaign for hand hygiene had been conducted in 2004 in NO, 
in 2008 in IT, in 2009 in DK, in 2010 in the UK and EL and in 2011 in the remaining 12. The 
campaign was aimed at professionals in all cases except in DK, at patients and at the general 
public in 12 and 11 cases respectively at the national level (at the regional level in the Spanish 
and Italian responding regions, in 5 out of 12 and 4 out of 12 respectively). 

On topics other than hand hygiene, national guidelines for prevention and control of HAI in 
hospitals  were  available  in  23  out  of  28  (all  but  CZ,  EE,  LV,  PL,  RO)  countries16  (82%). 
Guidelines  were  under  preparation  in  three  (CZ,  EE,  PL).  LV  and  RO  had  no  agreed 
guidelines. Two Spanish regions and two Italian regions reported no regional guidelines but 
some were available at the national level. 

14 

15 
16 

Commission  Staff  Working  Document,  accompanying  document  to  the  second  report  from  the 
Commission  to  the  Council  on  the  basis  of  Member  States’  reports  on  the  implementation  of  the 
Council Recommendation (2002/77/EC) on the prudent use of antimicrobial agents in human medicine. 
Available from: http://ec.europa.eu/health/antimicrobial_resistance/docs/cswd_technicalannex_en.pdf 
http://halt.wiv-isp.be 
Including the UK which responded at the regional level only. 

EN 

47 

   EN 

 
                                                 
At the national level, most frequent topics addressed in guidelines (in more than 80% of 22 
countries  with  guidelines)  were:  prevention  of  catheter-related  bloodstream  infections; 
prevention  of  HAI  in  general,  prevention  of  surgical  site  infections  and  perioperative 
prophylaxis; prevention of ventilator-associated pneumonia, and prevention of MRSA (Figure 
13). 

At  the  regional  level,  most  frequent  topics  addressed  in  guidelines  (in  more  than  2/3  of  13 
regions  with  guidelines)  were:  prevention  of  surgical  site  infections  and  perioperative 
prophylaxis and prevention of HAI in general (Figure 14). 

Guidelines regarding HAI prevention and control in nursing homes had been developed in 20 
out of 28 countries (71%): those with guidelines for hospitals except for CY, MT and PT. At 
the  national  level,  most  frequent  topics  addressed  in  guidelines  for  nursing  homes  (in  more 
than  2/3  of  countries  with  national  guidelines)  were  prevention  of  MRSA,  of  C.  difficile 
infections, of acute gastroenteritis (Figure 13). 

At  the  regional  level,  among  the  eight  regions  that  reported  guidelines  for  nursing  homes 
(Catalonia,  Ceuta  and  Melilla;  Apulia,  Autonomous  Province  of  Trento,  Emilia-Romagna, 
Friuli-Venezia  Giulia;  England,  Scotland),  prevention  of  HAI  in  general  and  prevention  of 
catheter-related urinary tract infections were the most frequent, in more than 2/3 (Figure 14). 

EN 

48 

   EN 

 
Catheter-related bloodstream infection 

Healthcare-associated infections (in general)

Prevention of surgical site infections
and perioperative prophylaxis 

Staphylococcus aureus resistant to meticillin (MRSA)

Ventilator-associated/hospital-acquired pneumonia 

Catheter-related urinary tract infections 

Communication on infectious status at discharge or when 
transferred to another healthcare institution

Healthcare-associated tuberculosis

Screening policy of patients transferred
from an hospital in another country

Clostridium difficile infection

Screening policy of patients transferred
from another hospital in the same country

Extended-spectrum beta-lactamase (ESBL)-
producing Enterobacteriaceae

Other multidrug-resistant Gram-negative bacteria
e.g., carbapenem-resistant bacteria) 

Enterococci resistant to vancomycin (VRE)

Multidrug-resistant bacteria (in general)

19

18

18

18

18

17

17

16

15

14

14

13

10

10

10

0

5

10

15

20

Number of  countries with guidelines f or hospitals

Staphylococcus aureus resistant to meticillin (MRSA)

Clostridium difficile infection

Acute gastroenteritis (e.g. Norovirus infections)

Communication/Information on infectious status 

Healthcare-associated infections (in general)

Catheter-related urinary tract infections

Catheter-related bloodstream infection

Respiratory tract infections

Healthcare-associated tuberculosis

Multidrug-resistant bacteria (in general)

15

13

13

12

11

11

11

8

8

7

0

5

10

15

20

Number of countries with guidelines for nursing homes

Figure 13: Topics addressed by national guidelines for prevention and control of HAI in hospitals (in 22 
countries) and in nursing homes (in 19 countries) 

EN 

49 

   EN 

 
 
 
Prevention of surgical site infections and perioperative prophylaxis 

Healthcare-associated infections (in general)

Catheter-related bloodstream infection 

Catheter-related urinary tract infections 

Staphylococcus aureus resistant to meticillin (MRSA)

Healthcare-associated tuberculosis

Clostridium difficile infection

Ventilator-associated/hospital-acquired pneumonia 

Communication/Information on infectious status of the patient at 
discharge or when transferred to another healthcare institution
Screening policy of patients transferred from another hospital in the 
same country

Extended-spectrum beta-lactamase (ESBL)-producing 
Enterobacteriaceae

Other multidrug-resistant Gram-negative bacteria (e.g., carbapenem-
resistant bacteria) 

Multidrug-resistant bacteria (in general)

Screening policy of patients transferred from an hospital in another 
country

Enterococci resistant to vancomycin (VRE)

9

8

7

7

6

6

5

4

4

4

4

4

4

3

3

0

2

4

6

8

10

Number of regions with guidelines for hospitals 

7

6

6

Healthcare-associated infections (in general)

Catheter-related urinary tract infections

Healthcare-associated tuberculosis

Catheter-related bloodstream infection

Clostridium difficile infection

Communication/Information on infectious status 

Staphylococcus aureus resistant to meticillin (MRSA)

Acute gastroenteritis (e.g. Norovirus infections)

Respiratory tract infections

Multidrug-resistant bacteria (in general)

4

3

3

2

2

2

2

2

0
8
4
Number of regions with guidelines for nursing homes

6

Figure 14: Topics addressed by regional guidelines for prevention and control of HAI in hospitals (in 11 
regions) and in nursing homes (in 8 regions) 

EN 

50 

   EN 

 
 
 
Sixteen countries (BE, BG, CZ, DE, DK, EL, FR, LT, LU, MT, NL, NO, PL, PT, SE, SI) and 
nine regions (Basque country, Catalonia, Ceuta and Melilla, Community of Madrid; Emilia-
Romagna, Friuli-Venezia Giulia, Piedmont; England, Scotland) reported having incentives for 
the implementation of some or all of the guidelines. These incentives were health inspections 
in 13 countries and two regions, certification/accreditation processes in 11 countries and five 
regions, and other encouragements in three countries and three regions (for instance, impact 
on reimbursement in Ceuta and Melilla). 

2.3. 

Infection prevention and control at the level of healthcare institutions 

Discussion on main findings 

legal  requirements  or  professional  guidelines  for  governance 
Most  countries  had 
arrangements in hospitals. Such requirements or guidelines for an appropriate organisation for 
prevention  and  control  of  HAI  in  nursing  homes  were  reported  in  less  than  half  of  the 
countries. 

As found in a previous survey17, the number of required infection control staff in hospital may 
vary  widely  from  one  country  to  another  and  even  inside  one  country,  from  one  region  to 
another. There is still a debate on how to define a target as the workload will depend on the 
duties  of  infection  control  staff,  on  the  type  of  clinical  activities  performed  and  on  the 
hospital’s  organisation  (inpatient  and  outpatient  activities  namely).  For  instance,  England 
advocated that giving prescriptive guidance on staffing levels could be detrimental given the 
wide variety of organisations, the fact that the number of beds – often used to define a ratio - 
does  not  take  into  account  patient  turnover  or  the  risk  arising  from  specialised  clinical 
activities. Some countries defined a ratio considering the number of beds allocated to “high 
risk” activities. In other countries, epidemiologists or consultant medical microbiologists may 
be  responsible  for  managing  infection  control  in  hospitals  as  part  of  their  job  on  the  top  of 
other daily activities. 

Global  evolution  in  healthcare  organisation  may  also  impact  the  workload:  decrease  in 
inpatient beds, increase of complex procedures performed in outpatients or in inpatients with 
reduced length of stay. Progress could be made by determining the duty of infection control 
staff  taking  into  account  the  type  of  care  provided  and  its  organisation,  and  by  improving 
education of infection control staff. 

The  issue  of  setting  up  an  appropriate  organisation  to  tackle  the  problem  of  HAI  and  of 
having qualified personnel is also crucial in nursing homes.  

Conclusions from ongoing European projects in this area could help in defining a minimum 
core of suitable competencies for hospitals and nursing homes. 

2.3.1.  Governance arrangements for hospitals 

There were legal requirements or professional guidelines for an infection control committee 
in hospitals in all but six countries (CZ, EE, LV, LT, RO, SE). 

17 

Weist  K,  Suetens  C,  Struelens  M.  Inventory  of  Antibiotic  Stewardship  and  Healthcare-Associated 
Infection Quality Indicators in EU Member States. BAPCOC/ECDC EU expert meeting – Workshop 2. 
November 2010, Brussels. 

EN 

51 

   EN 

 
                                                 
At  the  national  level,  nine  Member  States (BG,  DE,  EL,  FR,  HU,  IT,  PL,  PT,  SI)  had  both 
legal requirements and professional guidelines, six countries (AT, BE, ES, LU, NO, SK) had 
legal requirements; six Member States had professional guidelines (CY, DK, FI, IE, MT, NL). 
When requirements or professional guidelines were in place, they included involvement of the 
management in the infection control committee. 

At the regional level, 12 regions (Andalusia, Basque Country, Catalonia, Ceuta and Melilla, 
Community  of  Madrid;  Apulia,  Autonomous  Province  of  Trento,  Emilia-Romagna,  Friuli-
Venezia  Giulia,  Piedmont;  England,  Scotland)  had  legal  requirements  or  professional 
guidelines for an infection control committee in hospitals. They included involvement of the 
management  in  11  regions  (Andalusia,  Basque  Country,  Catalonia,  Ceuta  and  Melilla, 
Community of Madrid; Apulia, Emilia-Romagna, Friuli-Venezia Giulia, Piedmont; England, 
Scotland). 

Regarding infection control teams, all but four Member States (CZ, EE, LU, SK (had legal 
requirement for epidemiologist)) had legal requirements or professional guidelines. 

At the national level, 10 Member States (BG, DE, EL, FR, HU, IT, PL, PT, SE, SI) had both 
legal  requirements  and  professional  guidelines,  seven  countries  (AT,  BE,  ES,  LT,  LV,  NO, 
RO)  had  legal  requirements,  and  six  Member  States  (CY,  DK,  FI,  IE,  MT,  NL)  had 
professional guidelines. 

At the regional level, 13 regions (Basque Country, Catalonia, Ceuta and Melilla, Community 
of Madrid; Aosta Valley, Apulia, Autonomous Province of Trento, Emilia-Romagna, Friuli-
Venezia  Giulia,  Liguria,  Piedmont;  England,  Scotland) had legal requirements or guidelines 
for infection control teams. 

There  were  legal  requirements  for  a  dedicated  budget  at  the  hospital  level  in  five  Member 
States (AT, BE, BG (also with professional requirements), FR, SE). There were professional 
guidelines  on  this  issue  in  NL  and  in  Scotland.  Two  regions  had  legal  requirements  for  a 
dedicated budget for infection prevention and control (Catalonia; England). 

Overall, only CZ and EE had no requirements for governance arrangements in hospitals. 

2.3.2.  Governance arrangements for nursing homes  

Twelve countries (BG, DE, DK, FI, FR, IT, LU, NO, PT, RO, SE, UK) reported encouraging 
nursing  homes  to  have  in  place  appropriate  organisational  governance  arrangements  for  the 
elaboration and monitoring of a programme for infection prevention and control. In addition, 
five Member States (AT, BE, CZ, IE, HU) reported being in the process of developing such 
encouragements. 

Regarding infection control structures, two countries had legal requirements (NO, RO), three 
had professional guidelines (DK, FR, SE) and four had both (BG, DE, IT, PT). 

Trained contact points were required by legal requirements in NO, by professional guidelines 
in  three  Member  States  (DK,  FR,  SE),  or  by  both  in  four  Member  States  (BG,  FI,  IT,  PT). 
Outbreak  contact  points  were  also  required  by  legal  requirements  in  NO,  by  professional 
guidelines  in  five  Member  States  (DE,  DK,  FI,  FR,  SE),  or  by  both  in  two  Member  States 
(BG, IT). 

EN 

52 

   EN 

 
Five regions (Ceuta and Melilla; Emilia-Romagna, Friuli-Venezia Giulia; England, Scotland) 
reported  encouraging  nursing  homes  to  have  in  place  appropriate  organisational  governance 
arrangements for the elaboration and monitoring of a programme for infection prevention and 
control. These arrangements covered infection control structure in all regions, suitably trained 
contact  person  for  coordination  in  all  regions  but  Scotland  and  trained  contact  points  for 
outbreaks in all regions but Friuli-Venezia Giulia. In addition, two Spanish regions reported 
being in the process of developing such encouragements. 

2.3.3.  Qualified personnel 

The  ratio  for  the  number  of  infection  control  nurses  (full  time  equivalent)  according  to 
healthcare institution activity had been agreed in 17 countries: 11 had legal requirements (AT, 
BE, BG, EE, FR, HU, LT, LU, PL, PT, RO), five had professional guidelines (CY, EL, ES, 
NL, NO) and one had both (DE). At the regional level, 3 out of 5 Spanish regions (in addition 
to  the  national  ratio)  and  4  out  of  8  Italian  regions  reported  an  agreed  ratio  (professional 
guidelines  in  the  Spanish  regions  and  one  Italian  region,  legal  requirements  in  three  Italian 
regions). The value of the ratio had been provided by all 17 countries and four regions (Table 
9). 

Only four Member States (AT, NL, PL, PT) and one Spanish region (Ceuta and Melilla) had 
agreed  such  ratio  for  nursing  homes.  Two  had  legal  requirements:  PT  (same  ratio  than  for 
hospitals) and PL (in nursing homes  managed by hospitals,  therefore  submitted to the same 
ratio). Two Member States had professional guidelines: NL (the number of hours needed was 
estimated as 513 per 100 beds, or 154 per 10 000 care-days per year for infection control staff 
in general), and AT (ratio not specified). Ceuta and Melilla reported the same ratio than for 
hospitals. 

The  ratio  for  the  number  of  infection  control  doctors  (full  time  equivalent)  according  to 
healthcare institution activity had been agreed in 15 countries: 10 by legal requirements (BE, 
BG, EE, EL, FR, HU, LT, PL, RO, SK) and five by professional guidelines (AT, DE, ES, NL, 
NO). In addition to the nationally agreed ratio, three Spanish regions (professional guidelines) 
and four Italian regions (legal requirements for three and no information for one) reported a 
regionally  agreed  ratio.  The  ratio  had  been  specified  by  all  15  countries  and  four  regions 
(Table 9). 

Only one country and one Spanish region had agreed such ratio for nursing homes, by means 
of  professional  guidelines:  NL  (the  number  of  hours  needed  was  estimated  as  513  per  100 
beds, or 154 per 10 000 care days per year for infection control staff in general) and Ceuta and 
Melilla (same ratio than hospitals). 

LT reported having a ratio for outpatient healthcare facilities (one infection control doctor or 
infection  control  specialist's  assistant  for  100 000  visits  per  year  and  one  infection  control 
nurse for 50 000 – 100 000 visits per year). 

Table 9: Ratio for infection control staff in hospitals 

for 
Ratio 
control nurses (ICN) 

infection

Ratio  <  1 
ICN/ 
250 
beds 

Ratio  =  1 
ICN/ 
250 
beds 

Ratio  >  1 
ICN/  250 
beds) 

Ratio  using  denominator 
other  than  the  number  of 
beds  

Countries 

ES (P) 

BG (L) 

BE (L) 

(L):  0.25 

LU 
time 
equivalent (FTE) ICN per 100 

full 

EN 

53 

   EN 

 
AT (L) 

EE (L) 

CY (P) 

NO (P) 

EL (P) 

FR (L) 

LT (L) 

PL (L) 

PT (L) 

DE (L,P) 

FTE employees  

NL  (P):  1  FTE  per  5 000 
admission 

RO  (L):  2  ICN  per  secondary 
hospital  

HU  (L):  2  ICN  per  secondary 
hospital,  3  ICN  per  tertiary 
hospital 

Regions 

Community  of 
Madrid (P) 

Ceuta  and 
Melilla (P) 

Basque 
country (P) 

Friuli-Venezia 
Giulia (L) 

for 
Ratio 
control doctors (ICD) 

infection

Less  than  1 
ICD/ 
500 
beds 

Ratio  =  1 
ICD/ 
500 
beds 

More  than 
1 ICD/ 500 
beds) 

Ratio  using  denominator 
other  than  the  number  of 
beds 

Countries 

FR (L) 

BG (L) 

NO (P) 

BE (L) 

EE (L) 

LT (L) 

AT (L) 

1 

(P): 

medical 
NL 
microbiologist 
or 
epidemiologist  per  25 000 
admissions  

ES,  SK 
epidemiologist) per hospital 

(P):  1 

ICD (or 

RO  (L):  1  ICD  per  secondary 
hospital 

HU  (L):  Part-time  doctor  per 
secondary hospital 

At  least  one  FTE  in  tertiary 
hospital 

EL  (L):  Involvement  of  the 
clinical  microbiologist  and  of 
the 
disease 
specialist 

infectious 

PL  (L):  Involvement  of  the 
clinical microbiologist 

DE  (P):  1  ICD  per  hospital  > 
400 beds 

Regions 

Ceuta 
Melilla (P) 

and 

Basque 
Country 
(P) 

Friuli-Venezia  Giulia 
(P):1 
ICD (or  epidemiologist)  per 
hospital 

EN 

54 

   EN 

 
 
 
 
Community  of 
Madrid (P) 

P: professsional guidelines; L: legal requirements 

2.4. 

Surveillance systems 

Discussion on main findings 

Surveillance of HAI was performed in all countries, although not always through dedicated 
networks for surveillance. European projects on HAI (HELICS, IPSE, EARSS, now EARS-
Net) have played a role in promoting the development of sustainable surveillance networks as 
already  underscored  in  200818.  Increasing  the  coverage  of  those  surveillance  networks  and 
implementing external quality assessment for antimicrobial susceptibility testing may still be 
an  objective  in  some  countries.  Systems  involving  health  authorities  and  reference 
laboratories to help healthcare institutions to respond to alerts are in place in most countries. 

countries,  namely 

Systems for timely detection and reporting of selected events are in place in more than half 
of 
carbapenemase-producing 
Enterobacteriaceae  upon  which  a  strong  emphasis  had  been  put  in  2010  and  201119. 
Implementation of such systems in all countries would reinforce the ability to halt the spread 
of these emerging bacteria and prevent their introduction into healthcare settings as a result of 
cross-border transfers of patients. 

emerging 

threats 

such 

for 

as 

2.4.1.  National or regional networks for surveillance 

All  but  two  countries  (EE,  MT)  had  at  least  one  surveillance  network  dedicated  to  HAI  in 
place.  In  EE  and  MT,  surveillance  was  performed  at  the  hospital  level  and  not  through  a 
national or regional network. The median number of networks was 5 per country. 

The  most  widespread  surveillance  networks  targeted  multi-drug  resistant  bacteria  (MDRB), 
surgical site  infections (SSI), infections in  adult intensive care  units (ICU) and bloodstream 
infections (Figure 15). 

18 

Second  report  from  the  Commission  to  the  Council  on  the  basis  of  member  states’  reports  on  the 
implementation of the Council recommendation (2002/77/ec) on the prudent use of antimicrobial agents 
in 
http://eur-
Available 
141 
(COM(2010) 
lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2010:0141:FIN:EN:PDF. 

medicine 

human 

final). 

from: 

and 

data 

European  centre  for  disease  prevention  and  control.  Annual  epidemiological  report  2011.  Reporting  on  2009 
from: 
epidemic 

surveillance 
http://www.ecdc.europa.eu/en/publications/Publications/1111_SUR_Annual_Epidemiological_Report_
on_Communicable_Diseases_in_Europe.pdf. 
European centre for disease prevention and control. Risk assessment on the spread of carbapenemase-
producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special 
emphasis 
from: 
http://ecdc.europa.eu/en/publications/Publications/110913_Risk_assessment_resistant_CPE.pdf. 

cross-border 

intelligence 

Available 

Available 

transfer. 

2011. 

2010 

data. 

on 

19 

EN 

55 

   EN 

 
                                                 
MDRB incidence

SSI Incidence

Adult ICU incidence

Bloodstream infections incidence

CDI incidence

Prevalence surveys

Neonatal ICU incidence

National network

National and regional 
networks
Only regional  network

0

5

10

15

20

25

Number of countries 

Figure 15: Number of countries with national and/or regional networks for surveillance of healthcare 
associated infections (N=26) 

Prevalence  surveys  had  been  performed  in  the  previous  20  years  in  19  countries  (BE,  BG, 
CY,  CZ,  DE,  DK,  ES,  EL,  FI,  FR,  IE,  LT,  NL,  NO,  PT,  SE,  SI,  SK,  UK):  median  year  of 
performance: 2006, min: 1987 in SK, max: 2011. At the regional level, four Spanish and three 
Italian regions had performed such surveys. 

2.4.2.  Alert and reporting systems 

All  but  three  countries  (CY,  LT,  LU)  had  systems  organising  the  timely  detection  and 
reporting of alert healthcare associated events to the relevant body (alert meaning “new and 
threatening”).  In  ES  and  IT  some  systems  could  be  voluntary  at  the  national  level  and 
mandatory in some regions.  

The system covered clusters of HAI (some or all) in 22 countries (88%) and pathogen-specific 
targets  in  22  countries  (Figure  16).  Timely  detection  and  reporting  of  carbapenemase-
producing Enterobacteriacae was in place in 20 countries (AT, BE, BG, CZ, DE, DK, EL, ES, 
FI, FR, HU, NO, IE, IT, MT, PT, SE, SI, SK, UK) and of all cases of MRSA in 18 countries. 
BG,  HU  and  Scotland  also  mentioned  other  target  alert  organisms  in  addition  to  those 
specified  in  the  questionnaire,  e.g.  carbapenem-resistant  P.  aeruginosa  and  Acinetobacter 
baumannii, vancomycin-resistant Enterococcus, multidrug-resistant Pseudomonas, multidrug-
resistant Stenotrophomonas. 

Fifteen countries (BE, EL, ES, DE, DK, FI, FR, HU, IE, IT, NO, PT, SE, SK, UK) and three 
regions  (Catalonia,  Ceuta  and  Melilla;  Emilia-Romagna)  responded  that  data  from  these 
systems were available in reports or websites. 

EN 

56 

   EN 

 
 
Clusters of some HAI

Carbapenemase-producing 
Enterobacteriacae

Clusters of HAI (all)

MRSA, all cases

Clostridium difficile infections

ESBL-producing Enterobacteriacae

Alert HAI (e.g. severe infections)

MRSA, BSI only

Mandatory

Voluntary

0

5

10

15

20

25

Number of countries 

Figure 16: Number of countries with a system for timely detection and reporting of selected events (N=24) 

National  or  regional  institutions  with  the  mission  of  helping  to  respond  to  alerts,  support 
outbreak investigations, and define measures for prevention and control were in place in all 
countries  but  LV  and  CZ.  These  institutions  were  located  at  the  national  level  (Ministry  of 
Health,  national  public  health  institute  in  charge  of  surveillance/epidemiology,  health 
protection  agencies,  specialised  national  institutions  such  as  hygiene  institute,  reference 
centres  for  infectious  diseases,  antibiotic  resistance,  nosocomial  infections),  and/or  at  the 
regional  level:  regional  health  authorities,  regional  dedicated  centres  (for  instance,  in  FR: 
inter-regional  and  regional  nosocomial  infection  control  coordinating  centres;  in  NL: 
municipal health services for regional outbreaks).  

Reference  laboratories  in  charge  of  characterisation  of  antimicrobial  resistance  mechanisms 
were in place in 20 countries (AT, BE, BG, CZ, DE, DK, EL, ES, FI, FR, HU, IT, LT, LU, 
NO,  PL,  PT,  RO,  SE,  UK)  and  under  preparation  in  NL  and  SK.  Reference  laboratories  in 
charge of providing support in outbreak investigations were in place in 19 countries (AT, BE, 
BG,  DE,  DK,  EL,  ES,  FI,  FR,  HU,  IT,  LT,  MT,  NL,  NO,  PL,  PT,  SE,  UK)  and  under 
preparation  in  LU  and  SK  (SK  underscored  difficulties  resulting  from  limited  human  and 
financial resources). 

A system for external quality assessment of antimicrobial susceptibility testing was in place in 
19 countries (AT, BE, BG, CZ, DE, ES, DK, FI, FR, HU, IT, LT, LU, NL, NO, PL, PT, SE, 
UK) and under preparation in three (EE, EL, SK). No system had been set up in six Member 
States (CY, IE, LV, RO, SI, MT). In IT and ES, there could be regional systems in addition. 

2.5. 

Education and training of healthcare workers 

Discussion on main findings 

EN 

57 

   EN 

 
 
There is still room for progress regarding the training of healthcare workers. 

Many  countries  reported  that  various  trainings  exist  for  infection  control  staff  either  as 
continuing  education  programmes  or  in  the  form  of  occasional  educative  actions.  However, 
the required qualification to work as infection control staff is not uniform. Conclusions from 
ongoing  European  projects  in  this  area  could  help  in  defining  a  minimum  core  of  suitable 
competencies for hospitals and nursing homes. 

In  addition  to  pre-graduate  education,  continuing  education  is  crucial  on  topics  such  as 
infection  control.  However,  such  mechanisms  are  mandatory  in  only  about  half  of  the 
countries. The issue of strengthening continuing education had already been pointed out in the 
Second report from the Commission to the Council on the basis of Member States’ reports on 
the  implementation  of  the  Council  recommendation  (2002/77/EC)  on  the  prudent  use  of 
antimicrobial agents in human medicine (COM(2010) 141 final)20. 

2.5.1.  Education and training of infection control staff  

Thirteen  countries  (AT,  BE,  BG,  DE,  DK,  ES,  FI,  HU,  IT,  LT,  NL,  NO,  PT)  and  Scotland 
reported  having  a  nationally  agreed  common  core  of  competencies  (curriculum)  for 
specialised training on infection prevention and control for the infection control staff. Three 
Member States were developing such curriculum (PL, SI, SK). 

Non-sponsored continuing specialised training was mandatory for infection control doctors in 
nine  Member  States  (AT,  BE,  BG,  FR,  HU,  NL, PL, PT, SK) and three regions (Catalonia, 
Community of Madrid; Scotland), and, for infection control nurses, in 11 countries (AT, BE, 
BG, CZ, FR, HU, LT, NL, NO, PL, PT) and three regions (Catalonia, Community of Madrid; 
Scotland). 

2.5.2.  Education and training of healthcare workers 

There  was  a  nationally  agreed  common  core  of  competencies  for  education  of  healthcare 
workers  on  basic  principles  of  hygiene  and  infection  prevention  and  control  in  13  countries 
(AT, BG, DE, ES, FR, IT, LU, LV, NO, PT, RO, SK, UK) and one (SI) was in the process of 
developing such curriculum. 

A  system  to  provide  training  at  induction  for  all  healthcare  workers  was  mandatory  in 
healthcare institutions in 12 countries (BG, CZ, DK, FR, IE, LV, NO, PT, RO, SE, SK, UK) 
and  five  regions  (Andalusia,  Basque  Country,  Community  of  Madrid;  Emilia-Romagna, 
Friuli-Venezia  Giulia).  A  system  to  provide  regular  training  for  all  healthcare  workers  was 
mandatory  (binding  regulation)  in  healthcare  institutions  in  14  countries  (BG,  CY,  CZ,  FR, 
HU, IE, LV, NO, PT,  RO,  SE, SI, SK,  UK)  and eight regions (Andalusia, Basque Country, 
Ceuta  and  Melilla,  Community  of  Madrid;  Apulia,  Emilia-Romagna,  Friuli-Venezia  Giulia, 
Piedmont); these systems included training to managers in CZ, SK, UK, Andalusia and Friuli-
Venezia Giulia. 

2.6. 

Information to patients by healthcare institutions 

Discussion on main findings 

20 

http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2010:0141:FIN:EN:PDF. 

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In line with the principles of the Recommendation, enhanced involvement of patients in the 
process  of  care  relies  on  the  provision  of  appropriate  information,  in  particular  regarding 
adverse  effects  such  as  HAI  and  regarding  measures  to  prevent  them  (for  instance,  acute 
gastroenteritis and respiratory tract infections in long-term care and nursing homes). 

information 

institutions; 

National/regional  templates  for  patient  information  are  not  widely  spread,  but  countries 
reported  actions  to  encourage  provision  of  information  to  patients  on  HAI.  However, 
respondents  claimed  that  other  ways  of  informing  patients  were  used:  involvement  in 
regional  health 
regional/national 
authorities/public  health  services  through  websites;  public  campaigns  dealing  with  general 
preventive  measures  (namely  during  the  European  Antibiotic  Awareness  Day,  the  hand 
hygiene day, and campaign addressing flu prevention). Nevertheless, efforts are needed in this 
area  to  contribute  to  patients’  empowerment  and  improve  their  safety.  For  example, 
involvement of infected or colonised patients in the compliance with control measures and in 
ensuring consistency in their observation throughout the process of care is crucial, along with 
improved communication between healthcare professionals. 

for  public  disclosed  by 

As mentioned above in relation to objectives set in national or regional action plans regarding 
patient information and their participation in the inter-sectoral mechanism, improvements are 
needed in this area. 

There  was  a  template  for  information  to  be  delivered  to  patients  during  their  stay  in  a 
healthcare institution including information on HAI in three Member States (DK, FR, SK) and 
in  five  regions  (Andalusia,  Catalonia,  Community  of  Madrid;  Piedmont;  Scotland).  These 
templates included information on the measures implemented by the healthcare institution to 
prevent  HAI  except  in  DK,  and  information  on  the  risk  of  HAI  except  for  SK.  In  addition, 
information  on  how  patients  can  help  to  prevent  infections  was  provided  in  four  templates 
(FR,  Scotland,  Andalusia,  Community  of  Madrid)  and  specific  information  for  patients 
colonised or infected with healthcare associated microorganisms in four templates (DK, FR, 
Andalusia, Scotland). 

Eleven  Member  States  (BG,  DK,  ES,  FR,  IE,  LT,  LU,  NL,  PL,  SK,  UK)  and  four  regions 
(Community of Madrid; Emilia-Romagna, Friuli-Venezia Giulia, Piedmont) reported having 
in place mechanisms to encourage healthcare institutions to deliver information to the patient. 
These mechanisms consisted of a binding regulation in six Member States (DK, ES, FR, LU, 
PL,  SK),  professional  guidelines  in  six  Member  States  (BG,  FR,  IE,  NL,  PL,  SK)  and 
Scotland, accreditation or certification systems in four Member States (DK, FR, PL, SK) and 
England.  Other  reported  mechanisms  were  guidelines  from  the  regional  health  service  and 
independent inspection. 

2.7. 

Research initiatives 

Discussion on main findings 

As highlighted before for antimicrobial resistance, there is a need to clearly identify priorities 
for research. In less than half of the countries, the Ministry of Health or Research and/or inter-
sectoral  mechanism  played  a  role  in  promoting  research.  Involvement  of  national/regional 
competent authorities, in coordination with European projects, could be enhanced. 

In  six  Member  States  (BE,  DE,  ES,  FR,  NL,  SK)  and  four  regions  (Andalusia,  Catalonia; 
Emilia-Romagna;  England),  calls  for  tender  on  HAI  (epidemiology,  new  preventive  and 

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therapeutic  technologies  and  interventions,  cost-effectiveness  of  infection  prevention  and 
control) could be launched under the auspices of the Ministry of Health or of Research. The 
inter-sectoral mechanism was involved in the definition of priorities for research in the field 
of infection prevention and control in ten Member States (BE, DE, DK, EL, ES, FR, HU, LU, 
NL and UK), Andalusia and Emilia-Romagna. 

2.8. 

Impact of the Recommendation 

Discussion on main findings 

Activities  had  been  initiated  long  before  the  adoption  of  the  Recommendation  in  most 
countries.  In  fact,  due  to  the  public  consultation  launched  end  2005  on  the  project, 
professionals and health authorities were already aware of its content. In addition, the Council 
Recommendation of 15 November 2001 on the prudent use of antimicrobial agents in human 
medicine  (2002/77/EC)21  already  included  criteria  on  infection  control  to  halt  the  spread  of 
infections  due  to  bacteria  resistant  or  not  to  antibiotics.  In  a  previous  report  from  the 
Commission22, it had been found that 22 out of 28 participating countries had implemented a 
national programme and had developed guidelines to tackle HAI. 

Nevertheless,  13  Member  States  and  five  regions  reported  that  the  adoption  of  the 
Recommendation had triggered initiatives. Remarkably, even in countries where activities and 
organisational  arrangements  to  prevent  and  control  HAI  could  date  back  from  long  before 
2009, the adoption of the Recommendation has acted as a trigger or a reminder, thus leading 
to update or reinforce the strategy or action plan, as suggested by the median date of update of 
action  plans.  One  participant  explained  that  Council  Recommendations  were  of  great 
importance to keep focus on HAI and antimicrobial resistance at a high level in the EU. 

Less  than  half  of  the  countries  in  2011  used  indicators  enabling  them  to  monitor  trends  in 
HAI. However, the situation could change in the near future due to current European projects 
in this area. 

2.8.1.  Reported impact 

Thirteen Member States (BG, CY, CZ, DE, EL, FI, FR, HU, IT, LV, PL, RO, SK) and five 
regions  (Andalusia,  Catalonia,  Community  of  Madrid,  Ceuta  and  Melilla;  Autonomous 
Province  of  Trento)  reported  that  the  adoption  of  the  Recommendation  had  triggered 
initiatives. In 15 countries (AT, BE, DK, EE, ES, IE, MT, LT, LU, NL, NO, PT, SE, SI, UK) 
and  five  regions  (Basque  Country,  Emilia-Romagna,  Friuli-Venezia  Giulia,  Lombardy, 
Piedmont), activities were already underway and the Recommendation had no acknowledged 
effect. 

21 
22 

OJ L 34, 5.2.2002, p. 13–16 
Second  report  from  the  Commission  to  the  Council  on  the  basis  of  member  states’  reports  on  the 
implementation of the Council recommendation (2002/77/ec) on the prudent use of antimicrobial agents 
in 
http://eur-
Available 
141 
(COM(2010) 
lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2010:0141:FIN:EN:PDF. 

medicine 

human 

final). 

from: 

Commission staff working document - Accompanying document to the second Report from the Commission to 
the  Council  on  the  basis  of  member  states’  reports  on  the  implementation  of  the  Council 
Recommendation  (2002/77/EC)  on  the  prudent  use  of  antimicrobial  agents  in  human  medicine  - 
Detailed  analysis  of  countries’  reports  on  the  implementation  of  the  Council  Recommendation 
(2002/77/EC)  on  the  prudent  use  of  antimicrobial  agents  in  human  medicine  (SEC(2010)  399  final). 
Available from: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=SEC:2010:0399:FIN:EN:PDF 

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Initiatives triggered, even in Member States with established strategies or action plans, were: 

• 

• 

• 

• 

• 

• 

• 

implementation of an inter-sectoral mechanism or equivalent system in nine Member 
States (BG, CZ, EL, FI, FR, HU, IT, PL, SK) and four regions (Catalonia, Ceuta and 
Melilla, Community of Madrid; Autonomous Province of Trento); 

elaboration or revision of the national/regional strategy in nine Member States (BG, 
CZ, DE, EL, FI, FR, HU, IT, PL) and Catalonia; 

launch  of  campaigns  for  information  of  healthcare  workers  in  eight  Member  States 
(BG, CY, DE, EL, FI, IT, LV, SK) and four regions (Andalusia, Catalonia, Ceuta and 
Melilla; Autonomous Province of Trento); 

implementation  of  indicators  in  six  Member  States  (BG,  CZ,  DE,  FI,  IT,  SK)  and 
five  regions  (Andalusia,  Catalonia,  Ceuta  and  Melilla,  Community  of  Madrid; 
Autonomous Province of Trento); 

promotion  of  infection  control  and  hospital  hygiene  in  other  healthcare  institutions 
than  hospitals  in  five  Member  States  (BG,  CY,  CZ,  FI,  FR)  and  three  Spanish 
regions (Andalusia, Catalonia, Ceuta and Melilla); 

launch of campaigns for information of patients in four Member States (BG, CY, FI, 
LV) and three Spanish regions (Andalusia, Catalonia, Ceuta and Melilla); 

other initiatives in four Member States (DE, FR, RO, SK) such as: reinforcement of 
the national programme for surveillance (1); increase of awareness (2); reinforcement 
in the involvement of patients in prevention at the local level (1). 

2.8.2. 

Indicators  that  could  be  used  to  assess  the  impact  of  the  Recommendation  on 
prevention and control of HAI activities and outcomes in hospitals 

Countries were asked to report values for indicators that could be used to assess the impact of 
the  Recommendation  on  prevention  and  control  of  HAI  activities  (control  and  preventive 
measures, resources, surveillance) and outcomes in hospitals. 

Thirteen countries (AT, DE, ES, EL, FI, FR, HU, IE, LT, LU, NL, NO, PT) and eight regions 
(Basque Country, Catalonia, Community of Madrid; Apulia, Autonomous Province of Trento, 
Emilia-Romagna,  Friuli-Venezia  Giulia;  England,  Scotland)  reported  using  the  indicators 
listed in the questionnaire. 

The  situation  regarding  the  amount  of  alcohol  hand  rub  product  used  in  hospitals  was 
monitored in four Member States (ES, FI, FR, LT) and three regions (Catalonia, Community 
of  Madrid;  Autonomous  Province  of  Trento).  In  addition,  DE,  DK,  HU  and  IE  reported 
having  a  system  in  place  (since  2007  in  IE,  2011  in  HU).  Measurement  unit  was  litres  per 
patient-days  in  three  Member  States  (ES,  FI,  LT)  and  two  regions  (Catalonia;  Autonomous 
Province  of  Trento),  litres  for  FR  (then  expressed  per  1000  patient-days  or  hospitalisation 
days), and litres per stay in the Community of Madrid.  

The situation regarding the achievement of national requirements for the number of full time 
equivalent infection control nurses in hospitals was monitored in five countries (FR, EL, LU, 
NO,  PT)  and  two  regions  (Basque  Country;  Apulia  –  although  not  having  specified  the 
requirement for this indicators). All but PT gave values for before and after the adoption of 

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the Recommendation. PT, NO, Basque Country and Apulia (in public hospitals) reported that 
all  hospitals  met  the  requirements  before  the  implementation  of  the  Recommendation.  EL 
reported  that  each  hospital  had  at  least  one  infection  control  nurse  but  did  not  give  more 
details on the achievement of a national ratio. In FR, around 98% hospitals met the national 
requirements in 2008 and in 2009. 

The proportion of hospitals performing surveillance of surgical site infections was monitored 
in nine countries (AT, ES, FI, FR, HU, LT, NL, NO, PT) and eight regions (Basque Country, 
Catalonia, Community of Madrid; Apulia, Autonomous Province of Trento, Emilia-Romagna, 
Friuli-Venezia  Giulia;  England).  Seven  countries  (AT,  FR,  HU,  NO,  NL,  PT,  LT)  and  six 
regions  (Basque  Country,  Catalonia;  Apulia,  Autonomous  Province  of  Trento,  Emilia-
Romagna, Friuli-Venezia Giulia) provided values for before and after 2009. Data showed an 
increase  in  the  coverage  in  most  countries  and  regions  (AT,  FR,  HU,  NL,  PT,  LT, 
Autonomous  Province  of  Trento).  In  NL,  the  increasing  participation  was  attributed  to  the 
development  of  the  programme  to  improve  patient  safety.  The  coverage  showed  a  slight 
decrease or remained stable in one country and in regions where coverage was already high 
such as NO, Basque Country, Catalonia, Apulia, Emilia-Romagna and Friuli-Venezia Giulia. 

Seven Member States (EL, ES, FR, HU, LT, LU, PT) and four regions (Autonomous Province 
of Trento, Emilia-Romagna, Friuli-Venezia Giulia; Scotland) reported using other indicators 
than the three listed in the questionnaire: 

• 

• 

• 

• 

PT  monitored  hand  hygiene  compliance  of  (number  of  actions/  number  of 
opportunities for hand hygiene). 

FR, EL, Autonomous Province of Trento and Friuli-Venezia Giulia collected data on 
the  number  of  hospitals  performing  hand  hygiene  campaigns  or  involved  in  hand 
hygiene  programmes.  This  number  (or  proportion)  had  increased  where  data  were 
provided for before and after the adoption of the Recommendation. 

FR, LU, LT and Emilia-Romagna surveyed the number or the proportion of hospitals 
with ICUs, or the number of ICUs, performing surveillance of infections in ICUs. 

Some  Member  States/regions  monitored  the  number  or  the  proportion  of  hospitals 
performing other surveillance: device-associated infections in HU; point prevalence 
surveys  in  ES  and  LT;  ventilator  associated  pneumonia  surveillance  in  Friuli-
Venezia Giulia; surveys on MDRB in EL and FR; on blood and body fluid exposures 
in FR. 

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 CONCLUSIONS  

Despite the short timeframe to respond, most countries returned their questionnaires on time. 
Some  of  the  questions  left  room  for  different  interpretations,  which  can  hamper  the 
comparability  of  answers.  This  questionnaire  was  a  self-assessment  exercise  rather  than  an 
external  evaluation,  hence  natural  variations  between  countries  regarding  the  practical 
implementation  of  recommendations  and  the  effectiveness  of  measures  implemented  could 
not  be  addressed.  In  countries  where  regional  authorities  play  a  major  role  in  public  health 
policies implementation, the participation of less than half of the regions can have an impact 
on the results (as it can be assumed that the most involved regions may have replied). Lastly, 
countries  that  have  regulatory  framework  with  requirements  for  hospitals  but  not  a  real 
strategy or action plan on HAI did not answer all questions. Nevertheless, these results give a 
relatively clear picture of the state of implementation of the Council Recommendation and the 
areas in which greater focus and further measures are needed. 

As some countries are still developing their policies, they could benefit from the experience of 
other  countries  regarding  the  implementation  measures  and  the  effectiveness  of  existing 
systems. Active participation in the Commission Patient Safety and Quality of Care Working 
Group,  in  the  joint  action  on  patient  safety  and  quality  of  care,  in  the  ECDC  Antimicrobial 
Resistance  and  Healthcare-Associated  Infections  Networks,  and  in  various  research  projects 
could  further  facilitate  mutual  learning.  The  Commission  services  intend  to  continue 
following up progress made in the implementation of the Recommendation and will support 
research projects and dissemination of their findings. 

Future work should contribute to the implementation of the provisions relating to safety and 
quality of healthcare of the cross-border healthcare Directive23, and take account of the close 
links  between  work  developed  under  the  areas  of  patient  safety,  healthcare  associated 
infections and antimicrobial resistance. 

Future work should also take account of the 5-year ‘Action plan against the rising threats from 
antimicrobial  resistance’24  issued  by  the  Commission  in  November  2011,  which  aims  at 
putting in place effective ways to prevent microbial infections and their spread. Strengthening 
infection  prevention  and  control  in  healthcare  settings  (action  n°4  of  the  action  plan) 
contributes to achieving this objective. 

In  a  context  of  financial  crisis,  it  is  even  more  important  to  ensure  the  efficacy  and  the 
sustainability  of  policies  on  patient  safety,  including  the  prevention  and  control  of  HAI. 
Finally,  it  is  crucial  that  decision  makers  are  committed  to  adapt  their  policies  to  the 
continuously evolving organisation of healthcare and to emerging threats. 

23 

24 

Directive  2011/24/EU  of  the  European  Parliament  and  of  the  Council  of  9  March  2011  on  the 
application of patients' rights in cross-border healthcare 
Communication from the Commission to the European Parliament and the Council. Action plan against 
the  rising  threats  from  antimicrobial  resistance  (COM(2011)  748  final).  Available  from:  http://eur-
lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2011:0748:FIN:EN:PDF 

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