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It is a mandatory HSE requirement that all SREs are reported on the National Adverse Event Management System (NAEMS), formerly the STARSWeb System, and through the Safety Incident Management Communication/Escalation Form process.
SREs must be reported within 24 hours to a senior accountable officer. It is also mandatory that investigations commence within 48-hours of the Executive becoming aware of the incident and that these investigations are completed within four months of commencing.
However, in a response to a Parliamentary Question from Fianna Fáil Health Spokesperson Deputy Billy Kelleher on the issue, the HSE revealed that between January and June 2016, only 36 per cent of all SREs were reported as having been notified within 24 hours to the senior accountable officer.
“It should be noted that at this stage in the development of the reporting process, the fact that notification to the senior accountable officer has not been reported, does not necessarily mean the notification has not happened,” according to the HSE.
The HSE said that the new National Incident Management System, which will become the source of information in relation to SREs, will improve the process of recording SREs.
In a separate response to Deputy Kelleher, regarding the percentage of mandatory investigations that commenced within 48 hours of the events occurring, the HSE replied that it is not always appropriate or possible to establish the investigation within this timeframe.
The HSE pointed out more detailed guidance on reviews is being developed as part of the revised safety incident policy and will be in line with the new national standards for the review of patient safety incidents from HIQA and the Mental Health Commission.
The HSE informed Deputy Kelleher in August that, to date, there were 34 SREs with investigation completion dates due.
The decision to establish a Framework for reporting SREs was introduced in March 2014 and the defined list of SREs and associated guidance for 2015 was published in January 2015.