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233 ‘serious events’ in healthcare in 19 months

The report provides a snapshot of SREs reported nationally by HSE-run and HSE-funded services (acute hospitals, mental health, primary care, social care and ambulance services).

Some 174 SREs occurred in acute hospitals, 30 in social care and 28 in mental health.The SREs are reported under six broad categories: care management (103), environment (57), surgical (23), patient protection (21), criminal (21), product/device (8).

The HSE says it wil continue to embed the reporting and learning from adverse events into the overall approach to improving patient safety. “While the HSE is publishing this report today, it is still too early to establish trends or to draw any general conclusions from the data,” the Executive said. “This report does, however, provide some understanding of adverse events across the health and social care system. Public reporting on the number and types of SREs is an important step in this journey.”

Commenting on the publication, Mr Patrick Lynch, HSE National Director Quality Assurance and Verification, said: “In addressing what are serious events in the lives of individuals, it is incumbent on all healthcare staff and managers to understand what went wrong, to learn from it and to respond openly and compassionately to those affected. The approach we are now taking to reporting and analysing SREs is in line with international best practice.”

SREs are a defined list of serious incidents, many of which may result in death or serious harm.

Some SRE categories are considered to be largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by the healthcare providers concerned (e.g. wrong site surgery).

Others are serious incidents that may not have been preventable or predictable but which need to be examined to determine if in these areas, safety was compromised or can be improved (e.g. patient falls).

The decision to establish a Framework for the Reporting SREs was introduced in March 2014 and the defined list of SREs and associated guidance for 2015 was published in January 2015.

During 2015, the HSE says it has placed a significant focus on the implementation of the SRE reporting system across what is “a large complex system”.

The numbers of SREs reported nationally in the first nine months of 2015 has increased when compared with 2014 and it is expected that the” quality of reporting” will continue to improve over time, stated the Executive.

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