REPORT FROM THE COMMISSION TO THE COUNCIL The Commission’s Second Report to the Council on the implementation of Council Recommendation 2009/C 151/01 on patient safety, including the prevention and control of healthcare associated infections
Date: 2014-06-19
Institutions: European Commission
Subjects: disease prevention, health care, health control, infectious disease, nursing staff, patient's rights, professional qualifications, quality standard, right to health, safety standard













EUR-Lex - 52014DC0371 - EN











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52014DC0371

REPORT FROM THE COMMISSION TO THE COUNCIL The Commission’s Second Report to the Council on the implementation of Council Recommendation 2009/C 151/01 on patient safety, including the prevention and control of healthcare associated infections /* COM/2014/0371 final */









Table
of contents
1. Introduction. 3
2. Implementation at Member‑State
level 3
Development of policies and
programmes on patient safety. 4
Patient empowerment 4
Reporting and learning
systems on adverse events. 5
Education and training of
healthcare workers. 5
State of implementation by
countries. 5
3. Coordination of work at
EU level 6
Exchange of knowledge,
experience and good practice. 7
Tools to support
implementation. 7
4. Research and Health
Programme. 8
5. Impact of the
Recommendation. 9
6. Areas of interest
identified by Member States and stakeholders. 9
7. EU action relating to
healthcare‑associated infections. 10
Legislative action. 10
Activities in the area of
surveillance. 11
Guidance documents and
reports. 11
8. Conclusions. 12
Healthcare‑associated
infections. 12
General patient safety. 13

1. Introduction

Council Recommendation 2009/C
151/01[1]
put forward a range of measures on general patient safety and
healthcare-associated infections (HAI) and invited the Commission to report on whether
the measures are working effectively and to consider the need for further
action.
The Commission’s first report,
which was published in 2012,[2]
demonstrated satisfactory progress in the development of national policies and
programmes on patient safety. It also identified areas requiring further
effort: the education and training of healthcare workers in patient safety,
empowering patients and developing a culture of learning from errors. 
The report showed uneven progress
across the EU. Some Member States reported that implementation had been slowed by
financial constraints resulting from the economic crisis. The Commission therefore
proposed that its monitoring of the implementation of the general patient
safety provisions be extended for another two years.
The part of this report
on general patient safety is based on Member States’ responses to a
questionnaire from the Commission, replies to the public consultation[3] and the
results of the Eurobarometer survey on citizens’ experience and perception of the
safety and quality of healthcare.[4]
It also presents EU-level activities supporting the implementation of the Recommendation
in the area of general patient safety.  
Recent findings by the European
Centre for Disease Prevention and Control (ECDC) show that HAI continue to be a
problem in Europe. The chapter on HAI presents EU-level activities in support
of Member States’ implementation of the Recommendation.

2. Implementation at Member‑State
level

This chapter summarises the main
action taken at Member‑State level and, where possible, its impact and progress
as compared with the situation in 2012. It is based on replies received from all
EU Member States;[5]
and from Norway and the South Denmark region[6]
who replied on a voluntary basis. References to ‘countries’ should be taken to
mean the EU Member States and Norway. The headings reflect the structure of the
Recommendation.

Development of
policies and programmes on patient safety

The Member States have made
progress on developing policies on patient safety since the Recommendation was
adopted. 26 countries developed or are finalising patient safety strategies or
programmes, either free-standing or under other national policies. More
countries provided supporting documents than in 2012 (21 in 2014 against eight
in 2012). Most gave examples of indicators to evaluate the strategies. 23
countries identified a competent authority responsible for patient safety (19
Member States in 2012), but only 16 provided documents to support this. All but
one authority cooperate with authorities in other countries, both within and
outside the EU.
All countries reported on patient
safety measures in place. Patient safety standards are mandatory in 20
countries (11 in 2012) and recommended in four others. 19 countries use patient
safety guidelines, in most cases developed at national level, by the health ministry
or a dedicated agency. However, the replies show that the understanding of
standards and guidelines varies across countries. Some countries report on specific
standards for a type of adverse event, others on quality management systems and
others take reporting and learning systems as examples. This makes it difficult
to assess and compare progress across the EU.
The Recommendation encourages
Member States to use information and communication systems to support the
development of national policies and programmes on patient safety. The replies
show that this provision is mainly understood as calling for websites with
information about policies. Only a few countries reported on the use of
reporting and learning systems, e-learning methods or electronic patient
registries.

Patient empowerment

The 2012 report concluded that
insufficient action had been taken to empower patients, both in terms of
involving patient organisations in policy making and informing patients on patient
safety measures.
24 countries said they involved patient
organisations in the development of patient safety policies (20 in 2012),
including 12 countries which provided examples of specific administrative and
legal acts requiring such involvement. In the majority of countries,
organisations can provide feedback, most often at meetings organised by competent
authorities or via public consultations.
With respect to individual
patients, Member States are recommended to disseminate information on patient
safety standards, safety measures to reduce or prevent errors, the rights to
informed consent to treatment, complaint procedures and available redress. Here,
considerable progress was reported: 18 countries provide patients with
information on all the above (only five in 2012) — with the right to informed
consent and complaint procedures being the most widely communicated. Among all
countries, only 18 gather feedback from patients about the availability and
accuracy of information provided, mostly via surveys.
The Recommendation called on
countries to develop core competencies for patients on patient safety. No
progress has been made in this field since 2012 as in many countries the term
remains unclear. It would therefore be appropriate to clarify this concept
further so as to foster common understanding and uptake by the Member States.  

Reporting and learning
systems on adverse events

Further progress was reported on
establishing reporting and learning systems. These exist in 27 countries (15 in
2012), mostly at national (21) and healthcare‑provider level (13). However,
where multiple systems are in place, they are rarely ‘interoperable’ (only seven
out of 26). Also, only six Member States’ systems fully respond to the Recommendation’s
requirements that they should:
-       
provide
extensive information about adverse events;
-       
be
differentiated from disciplinary procedures for healthcare workers;
-       
allow
patients to report; and 
-       
complement
other safety reporting systems, e.g. those on pharmacovigilance or radiation
safety.
Information from reporting
systems is mostly disseminated in newsletters, health ministry reports and at
conferences. Several countries use it to detect alerts, monitor trends and/or
produce guidelines or recommendations. Half the Member States with such
reporting systems share information so as to be able to learn from each other. However,
only a few countries reported that errors are analysed at healthcare‑provider
level and lessons are drawn to improve quality and safety. 
In 25 countries, reporting by
healthcare workers has increased over the past four years, but only 15
countries report the same with regard to patients. Both figures are higher than
in 2012.

Education and training
of healthcare workers

This area remains under‑implemented.
Most countries reported that they encouraged multidisciplinary training on
patient safety in healthcare settings, but three quarters do not provide information
about the actual delivery of such training in hospitals.
Patient safety is not widely
embedded in the undergraduate and postgraduate education of healthcare workers,
on-the-job-training and the continuing professional education of health
professionals, except in six Member States.[7]
In eight Member States, it is not formally required at any level or for any
health professionals. In countries with formal requirements to include patient
safety in education and training, patient safety is mostly part of
on-the-job-training for doctors, nurses and pharmacists.

State of implementation
by countries

Chart 1 shows implementation
progress by country, based on countries’ self-assessment as to whether the
following are in place: 
-       
patient
safety strategies; 
-       
competent
authority; 
-       
specific
measures to prevent medication errors, HAI and complications during or after
surgical intervention; 
-       
ICT
tools to support patient safety; 
-       
measures
to involve patient organisations in policy making; 
-       
measures
to ensure dissemination of information about patient safety to patients; 
-       
core
competencies for patients; 
-       
reporting
and learning systems in place;
-       
reporting
and learning systems fulfilling criteria as defined by the Recommendation; 
-       
mechanisms
to encourage reporting by health professionals; 
-       
multidisciplinary
training on patient safety in hospitals; 
-       
patient
safety embedded in the education and training of health professionals; and 
-       
measures
to inform health professionals about patient safety standards, guidelines or
best practices.
Chart 1:
Implementation by countries of the 13 measures analysed in this report[8] 
As the chart shows, most
countries have in place at least half the measures analysed in this report, a
few countries are close to full implementation of the 13 measures while 11 have
implemented less than half the recommendations.

3.
Coordination of work at EU level

In addition to action by Member
States, the Recommendation calls for action at EU level to develop common
definitions, terminology and comparable indicators, and share best practice. The
Commission has been coordinating the following activities in support of such
action:

Exchange of knowledge, experience and
good practice

The exchange of knowledge in
patient safety and quality of care is facilitated at EU level in two main fora.
One is the Commission’s working group on patient safety and quality of care,[9] which brings together
representatives of EU Member States and EFTA countries, international
organisations (WHO and OECD) and EU stakeholders: patients, health
professionals, healthcare managers and experts in quality of care. The working
group is consulted on current and planned activities in patient safety and
quality of care at EU level. It can also produce reports or recommendations at
the Commission’s invitation or on its own initiative. In addition, it provides a
platform for members to share knowledge about initiatives at national level,
stakeholders’ activities and the outcomes of research projects.
A second forum for the exchange
of good practice is an EU co-financed three-year joint action among Member States and stakeholders on patient safety and quality of care (PaSQ).[10] Its main tasks are to
identify existing safe clinical practices and good organisational practices in
the EU, to arrange for the exchange of knowledge about them and to test the transferability
of patient safety practices to healthcare settings in other countries.
The active participation of all
EU Member States, Norway and other stakeholders in this joint action and the success
of exchange mechanism events which took place in this framework confirm a clear
demand among stakeholders for this kind of cooperation at EU level. However, as
a time-limited financing mechanism, the joint action will come to an end in
March 2015. The Member States and other partners have suggested setting up a
permanent network which would continue and expand on the current activities. Possible
new activities which could be developed by such a network include a peer-review
system for healthcare quality improvement organisations and a mechanism for the
rapid exchange of patient safety incidents and solutions.

Tools to support implementation

To support implementation of the Recommendation,
the working group has produced practical guides on:
-       
the
education and training of health professionals in patient safety[11] – this provides a
catalogue of existing modules and programmes with their content, target
audience, faculty capacities, learning outcomes and evaluation. It also
includes a list of success factors in setting up patient safety modules and
training for different groups of health professionals at different levels; and
-       
the
effective setting‑up and functioning of reporting and learning systems[12]
– this refers
to existing knowledge and experience of how Member States have organised established
reporting systems. It includes practical recommendations, encourages a
reporting and learning culture and outlines the technical infrastructure required
for setting up and maintaining the systems.
To complement this work, the
Commission asked the WHO to adapt the Conceptual Framework (CF) for the International
Classification for Patient Safety[13]
for reporting on patient safety incidents in the EU. This consists of
developing a ‘minimal information model’ for reporting patient safety incidents,
to be used as a template by healthcare institutions to collect, review, compare
and analyse incident reports. The information model will be accompanied by
common terminology to designate and define the main types of patient safety
incidents.
The Commission has also co-financed
the OECD‑led Health Care Quality Indicators Project,[14] which
has developed a set of quality indicators, including patient safety, at health‑system
level, whereby the impact of particular factors on the quality of health
services can be assessed. 24 EU Member States and Norway currently participate
in the project.
In 2010, although not in response
to the Recommendation, EU pharmaceutical legislation[15] was
revised with respect to pharmacovigilance activities. Since July 2012, Member
States have been required to ensure that, where suspected adverse reactions
arise from an error associated with the use of a medicinal product, reports to
their pharmacovigilance reporting systems are also made available to the authorities
responsible for patient safety.
Finally, the Commission Green
Paper on mHealth[16]
highlights benefits of using telemedicine and mHealth solutions for ensuring
patient safety. 

4.
Research and Health Programme

The Commission has addressed
patient safety and HAI by funding several European-wide projects under the First
and Second Health Programmes and the Sixth and Seventh Framework Programmes for
Research and Technological Development. The Third Health Programme (2014-20)[17] and the new research programme
Horizon 2020 (2014-2020)[18]
provide for funding for further projects on patient safety and quality of
healthcare, including HAI.
At Member‑State level, research
programmes on patient safety have been developed in half of the Member States. A
lack of financial resources is reported as the main barrier to developing
research at national level.

5.
Impact of the Recommendation

This chapter is based on
information received from countries and complemented by results from the public
consultation and the Eurobarometer survey.
Countries’ replies show that the
Recommendation raised awareness about patient safety at political level (21
replies). In 16 countries, it triggered concrete national/regional action, such
as the development of patient safety strategies and programmes, the inclusion
of patient safety in health legislation or the creation of reporting and
learning systems. In some countries, it strengthened and supported existing
patient safety programmes and confirmed their consistency with EU policies.
According to countries’
self-assessments, the Recommendation raised awareness about patient safety at
healthcare setting level (20 replies). Only half of countries judged that it
had had an impact on empowering patient organisations and individual patients.
For 65 % of the respondents
to the public consultation, the Recommendation contributed to improving patient
safety. The replies confirm that it raised awareness at political level but
point to low levels of awareness in healthcare settings, in particular as regards
patient empowerment.
The Eurobarometer showed that the
Recommendation did not change EU citizens’ perception of the safety of care. As
in 2009, over 50 % of respondents thought that patients could be harmed by
hospital and non-hospital care.
Also, 25 % of respondents said
that they or their family experienced an adverse event. Patients now report considerably
more adverse events than in 2009 (46 % vs. 28 %). Most respondents felt,
however, that such reporting does not lead to specific action being taken.
Finally, EU citizens say that
they usually assess the quality of a particular hospital on the basis of its
general reputation or other patients’ opinions. This seems to indicate that
objective information about the quality of care in hospitals is not easily
accessible by patients.

6. Areas of interest
identified by Member States and stakeholders

In their contributions to this
Report, Member States identified the following areas for further cooperation at
EU level:

 patient safety policies and
     programmes (21 replies);
 the development of blame-free
     reporting and learning systems and encouraging reporting by both health
     professionals and patients (21 replies); and
 the development and review
     of patient safety standards (20 replies).

The Commission received 181
replies to the public consultation, the main contributors being health
professional organisations, patient and consumer organisations and hospitals. The
respondents identified a need for improvement in the following areas:

 patient safety in non-hospital
     care;
 ensuring education and
     training not only for health professionals, but also for patients,
     families and informal carers;
 encouraging the use of new
     technologies for the benefit of patient safety;
 supporting the harmonised EU‑wide
     surveillance of HAI and comprehensive assessment guidelines on patient
     safety standards complemented by checklists and indicators to be used
     across countries; and 
 ensuring equal possibilities
     of redress for errors in treatment for all EU citizens.

72 % of respondents think
there would be added value in enlarging the scope of EU action from patient
safety to the wider quality of care. Patient safety is seen as a result of good
quality healthcare. Specific proposed action at EU level included:

 establishing a common
     definition of ‘quality of care’;
 developing an EU strategy on
     health-related information for patients; 
 considering gathering patients’
     experience as an element of quality improvement systems;
 setting up a permanent
     European forum to promote and share best practice in patient safety and
     quality of care, building on the joint action, e.g. work on a system of quality
     standards in healthcare organisations, issuing guidelines, setting targets
     and benchmarking; and
 taking account of the impact
     of workforce shortages and working conditions on the quality of care and
     encouraging better coordination of care.

Many respondents said the
proposed action would also contribute to implementation of Directive 2011/24/EU.[19]

7. EU action relating to healthcare‑associated
infections

The Recommendation sets out action
to be taken on HAI by Member States and at EU level. The sections below present
steps taken at EU level to support Member States’ action.

Legislative action

The Recommendation
provides that Member States should use case definitions agreed at EU level to allow
consistent reporting of HAI. Commission Decision 2012/506/EU of 8 August 2012
includes in its annex general and specific systemic case definitions of HAI,
including reporting instructions for each of the conditions.[20] These
case definitions of HAI will help not only to considerably improve surveillance
across the EU, but will allow assessing the impact at EU level of the preventive
measures undertaken.
HAI are covered by the
new Decision No 1082/2013/EU on serious cross‑border health threats.[21] The
Decision strengthens the Health Security framework in the EU as regards
preparedness planning, risk assessment, risk management and coordinating
measures, including risk communication aspects.[22] Its provisions will
apply to HAI.[23]

Activities
in the area of surveillance

The ECDC network for the
surveillance of healthcare-associated infections (HAI-Net) coordinates
different modules to support Member States in establishing or strengthening the
active surveillance systems referred to in Article II.8.c of the Recommendation.
Since the Recommendation was published,
one EU-wide point prevalence survey was organised in acute care hospitals in
2011-12 (ECDC PPS)[24]
and two in long-term care facilities (LTCFs).[25]
Targeted surveillance of HAI was implemented continuously through the
surveillance of surgical site infections (SSIs) and the surveillance of HAI in
intensive care units (ICUs).
Overall, the level of
participation in the European HAI surveillance modules was considered high in nine
countries or regions (AT, DE, ES, FR, IT, LT, MT, PT and UK‑Scotland), medium
in 13 (BE, CZ, EE, FI, HU, LU, NL, NO, RO, SK, UK-England, UK-Northern Ireland
and UK-Wales) and low in 11 countries (BG, CY, DK, EL, HR, Iceland, IE, LV, PL,
SE and SI).

Guidance
documents and reports

The ECDC produced several
guidance documents and reports to support Member States: 
In the area of appropriate use of
antibiotics a systematic review and evidence-based guidance to improve the
compliance of healthcare professionals with appropriate administration, timing,
dosage and duration of perioperative antibiotic prophylaxis for the prevention
of surgical site infections was published.[26]  
In the area hospital infection
control programmes, a systematic review on hospital organisation,
management, and structures in place relating to healthcare-associated infection
prevention identified a manageable set of 10 key components of hospital
infection control programmes.[27]
 
For nursing homes and other
long-term care facilities, national performance indicators for infection
prevention and control and antimicrobial stewardship were developed and
assessed, which will be used as a basis for monitoring improvements of Member
States in this area. 
Finally, core competencies for
infection control and hospital hygiene professionals have been developed and
are already being used by Member States.[28]


8.
Conclusions
Healthcare‑associated infections

By leading to the adoption of a general
and specific case definition for HAI and providing a standardised methodology
and framework for the national surveillance of HAI, EU‑level action contributed
to strengthening HAI surveillance systems in the EU.
In particular, the ECDC’s Europe-wide
point prevalence survey of HAI and antimicrobial use in 2011-12 contributed to the
improved collection of data on HAI, even in Member States that had not previously
started with this activity.
The point prevalence report[29] and
the Commission’s first implementation report[30]
indicate that Member States should focus their efforts on ensuring the targeted
surveillance of HAI in surgical site infections, intensive care units and nursing
homes and other long-term care facilities.
Further measures by Member States
are needed to improve the routine case ascertainment of HAI, through the
development of national diagnostic guidelines, continued training of healthcare
workers in applying case definitions of HAI and the reinforcement of laboratory
and other diagnostic capacity in healthcare institutions. 
More specifically, the Europe-wide
point prevalence survey – highlighted the need to ensure 

 adequate numbers of
     specialised infection control staff in hospitals and other healthcare
     institutions  
 sufficient isolation
     capacity for patients infected with clinically relevant microorganisms in
     acute care hospitals  
 standardised surveillance of
     alcohol hand rub consumption.  

To further support Member States preventing and
control healthcare-associated infections and in supporting the implementation
of the Recommendation, both the Commission and ECDC have prioritised addressing
HAI.[31] 


General patient safety

The Recommendation has
successfully raised awareness about patient safety at political level and
triggered changes such as the development of national patient safety strategies
and programmes and the development of reporting and learning systems in many EU
Member States. It has created a climate that is conducive to improving patient
safety in the EU.
However, it has had less of an
impact in increasing patient safety culture at healthcare setting level, i.e. encouraging
health professionals to learn from errors in a blame-free environment. The
impact on empowering patients is only partial. The education and training of
health professionals remains an area in which Member States and stakeholders have
pointed to a need for further effort. Also, implementation of the
Recommendation has not strengthened EU citizens’ confidence in the safety and
quality of healthcare in their country.
Meanwhile, patient safety remains
an issue in the EU, as confirmed by over 90 % of responses to the public
consultation and by EU citizens’ perceptions. This is supported by research[32] highlighting
significant gaps between knowledge and practice in patient safety strategies
and arguing that a substantial proportion of European citizens are at risk of
receiving suboptimal care as a consequence.
In this context, the Commission
considers there is a need for continued effort at EU level to support Member
States in improving patient safety and quality of care. The following measures could
be of particular relevance for further EU work, in close collaboration with Member State  s and stakeholders:

 A common
     definition of quality of care and further support for the development of
     common terminology, common indicators and research on patient safety;
 EU collaboration
     on patient safety and quality of care to exchange good practices and
     effective solutions. This could build on the current joint action and be extended
     to other topics identified by Member States and stakeholders;
 Developing
     guidelines on how to provide information to patients on quality of care;
 Development with
     Member States of an EU template on patient safety and quality of care
     standards to achieve common understanding of this concept in the EU;
 Reflection with
     Member States on the issue of redress as provided for in Directive 2011/24/EU);
 Encouraging the development
     of training for patients, families and informal carers using also ICT
     tools; regular updating and dissemination of the guide on patient safety
     education and training for health professionals; and
 Encouraging reporting as a
     tool to spread a patient safety culture; regular updating and
     dissemination of the guide on the setting‑up and functioning of reporting
     and learning systems.

These measures could also support
an optimal implementation of Directive 2011/24/EU.
[1]     Council
Recommendation (2009 C 151/01) of 9 June 2009 on patient safety, including the
prevention and control of healthcare‑associated infections (OJ C 151, 3.7.2009,
p. 6).
[2]     Report
from the Commission to the Council on the basis of 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).
[3]     Report
of the public consultation on patient safety and quality of care, June 2014;
http://ec.europa.eu/health/patient_safety/policy/index_en.htm 
[4]     Eurobarometer
B80.2 Patient safety and quality of care published in June 2014; http://ec.europa.eu/health/patient_safety/policy/index_en.htm
[5]     DE
sent an off-line partial reply, included in the analysis.
[6]     When
Danish replies from regional and national level are the same, they are reported
as those of Denmark.
[7]     No
information from DE.
[8]     Only
full replies to the questions, i.e. including supporting documents or providing
examples, were acknowledged.
 [9]
   See http://ec.europa.eu/health/patient_safety/events/index_en.htm
[10]    See
http://www.pasq.eu/
[11]    Key
findings and recommendations on education and training in patient safety across
 Europe. Report of the Commission’s working group on patient safety and quality
of care. April 2014 http://ec.europa.eu/health/patient_safety/policy/index_en.htm

[12]    Key
findings and recommendations on reporting and learning systems for patient
safety incidents across Europe. Report of the Commission’s working group on
patient safety and quality of care. April 2014
http://ec.europa.eu/health/patient_safety/policy/index_en.htm 
[13]    http://www.who.int/patientsafety/implementation/taxonomy/conceptual_framework/en/
[14]    http://www.oecd.org/health/health-systems/healthcarequalityindicators.htm
[15]    Regulation
(EC) No 726/2004 of the European Parliament and of the Council of 31 March 2004
on Community procedures for authorisation and supervision of medicinal products
and establishing a European Medicines Agency, as amended by Regulation (EU) No
1235/2010 of 15 December 2010;      
Directive 2001/83/EC of the European Parliament and of the Council of 6
November 2001 on the Community code on medicinal products for human use, as
amended by Directive 2010/84/EU of 15 December 2010.
[16]   Green Paper on mobile Health
("mHealth") COM(2014) 219 final.
[17]    Regulation
(EU) No 282/2014 of the European Parliament and of the Council of 11 March 2014
on the establishment of a third Programme for the Union’s action in the field
of health (2014-2020) and repealing Decision No 1350/2007/EC (OJ L 86,
21.3.2014, p. 1).
[18]   Regulation (EU) No 1291/2013 of the European Parliament and of
the Council of 11 December 2013   
     establishing Horizon 2020 - the Framework Programme for Research and
Innovation (2014-2020) and 
     repealing Decision No 1982/2006/EC.
[19]    Directive
2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the
application of patient rights in cross-border care (OJ L 88, 4.4.2011, p. 45).
[20]    Commission
Implementing Decision 2012/506/EU amending Decision 2002/253/EC laying down
case definitions for reporting communicable diseases to the Community network
under Decision No 2119/98/EC of the European Parliament and of the Council (OJ
L 262, 27.9.2012, p. 40).
[21]    Decision No 1082/2013/EU of the European Parliament and of the
Council of 22 October 2013 on serious cross-border threats to health and
repealing Decision No 2119/98/EC (OJ L 293, 5.11.2013, p. 1).
[22]   Decision No 1082/2013/EU of the European Parliament and of the
Council of 22 October 2013 on serious
      cross-border threats to health and repealing Decision No 2119/98/EC (OJ L
293, 5.11.2013, p. 1)
[23]   HAI was covered by Decision No 2119/98/EC.
[24]   Point
prevalence survey of healthcare-associated infections and antimicrobial use in
European acute care
      hospitals, 2011-2012. Stockholm: ECDC; 2013
[25]   Point
prevalence survey of healthcare-associated infections and antimicrobial use in
European long-term care facilities. April–May 2013. Stockholm: ECDC, 2014; Point
prevalence survey of healthcare-associated infections and antimicrobial use in
European long-term care facilities. May–September 2010. Stockholm: ECDC; 2014
(both in press)
[26]   Systematic
review and evidence-based guidance on perioperative antibiotic prophylaxis. Stockholm: ECDC;
      2013 
[27]   These
key components include: 1) organisation of infection control on a hospital
level; 2) bed occupancy, 
      staffing, workload, and pool/agency nurses; 3) ergonomic aspects; 4)
appropriate use of guidelines; 5) 
      education and training; 6) auditing; 7) surveillance and feedback; 8) multimodal
and multidisciplinary 
      prevention programmes taking into account principles of behavioural
change; 9) engaging champions in 
      prevention programmes; and 10) the role of a positive organisational
culture. Zingg W, Holmes A, 
      Dettenkofer M, et al. Hospital organisation, management, and
structure in the context of healthcare- 
      associated infection prevention: a systematic review. Lancet Infect
Dis 2014: in press.
[28]    European
Centre for Disease Prevention and Control; Core competencies for infection
control and hospital hygiene professionals in the European Union. Stockholm: ECDC; 2013.
[29]    European
Centre for Disease Prevention and Control (ECDC); Point prevalence survey of
healthcare-associated infections and antimicrobial use in European acute care
hospitals: 2011-12. Stockholm: ECDC: 2013.
[30]    Report
from the Commission to the Council on the basis of 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).
[31]  For
example, ECDC will develop a repository of existing guidance and other
documents, to foster the 
    exchange of best practices and the development of such documents in
settings where they do not yet exist. 
    Furthermore, ECDC will develop a monitoring and evaluation system with a
set of indicators to assess the 
    implementation of national strategies/action plan and their success in
improving prevention and control of 
    HAI.
[32]  Sunol,
R. et al. 2014, Evidence-based organisation and patient safety strategies in
European hospitals.
    International Journal for Quality in Health Care 2014; pp. 1–9.