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The recommendations are published in conjunction with two supporting documents, the “As-is” analysis of patient safety intelligence systems and structures in Ireland and also with the International review of patient safety surveillance systems.
HIQA says services must share and act on information about patient safety incidents, and learn lessons to prevent similar incidents happening again.
The HIQA recommendations include the proposal for a new model for coordinating patient safety intelligence in Ireland and the implementation and rollout of the national incident management system. HIQA recommends the need to embed a ‘just culture’ within services to ensure timely review of incident information and place an emphasis at a local and national level to learn from such incidents.
Dr Kevin O’Carroll, Acting Director of Health Information with HIQA, commented: “Safe and reliable health and social care depends on access to, and use of, good quality information. The 10 recommendations published today by HIQA include assigning responsibility and accountability for national patient safety intelligence to an independent organisation in order to ensure effective national oversight of patient safety and also to inform policy development. Introducing these recommendations would enable risk profiling of services and greatly improve patient safety.
“There is currently no single agency in Ireland with responsibility for the governance and coordination of patient safety intelligence and for sharing learning between the numerous agencies which collect patient safety intelligence. The diffusion of this information is a lost opportunity to provide early warnings of potential patient safety risks.”
HIQA has also reported a need for an effective ICT infrastructure to assist the coordination of patient safety intelligence combined with effective governance arrangements for sharing learning from patient safety incidents locally and nationally. Implementing a national incident management system across the health and social care system, new legislation to support incident reporting, and improving data quality and use of incident information are also required.
HIQA’s recommendations follow public concern about the safety of Irish maternity services and were informed by a comprehensive review of patient safety intelligence systems in operation in other countries and a review of how patient safety intelligence is currently gathered and used in the Irish health service. In addition, key stakeholders from across the health and social care sector in Ireland also considered the options for patient safety surveillance in Ireland and helped to shape the HIQA recommendations.
Dr O’Carroll continued: “To inform our recommendations, we carried out an in-depth international review of patient-safety surveillance systems in health systems in four countries, namely Canada (in British Columbia), Denmark, England and Scotland. A key theme from this international review was the importance of coordinating and sharing patient safety intelligence.
“Many of the countries studied as part of this international review are now focusing on triangulating intelligence from the reporting and learning system with other sources of intelligence, such as from coroners’ reports, the public, and public health agencies, in order to identify patient safety concerns. This allows the pooling of patient safety intelligence from a range of sources to ensure a more accurate risk profile is identified.”
“The primary purpose of patient safety reporting systems is to learn from when things go wrong for patients and staff, and to try and prevent such incidents happening again. The most important function of a reporting system is to use the results of data analysis and investigation to share recommendations for addressing patient safety risks. These systems must encourage healthcare workers to actively report incidents through the establishment of a reporting environment which balances the need to learn from mistakes with accountability,” Dr O’Carroll added.
A review of what is currently being done in Ireland for reporting, analysing and implementing learning from patient safety incidents and adverse events at a national level showed that there is a need for better governance and coordination of national patient safety intelligence in Ireland.
These recommendations have been approved by the HIQA Board and have been sent to the Minister for Health for the Minister’s consideration.