Patient safety may be governed by agency

HEALTH chiefs are examining the case for setting up a Patient Safety Agency in the wake of findings that hospital mishaps affect over 1,000 patients weekly.

The biggest single category of incident involves slips, trips and falls by patients but the findings also cover a wide range of mistakes by medical staff including misdiagnosis, accidents with equipment, incorrect use of drugs and failure to secure proper consent for procedures.

Some of the incidents are classified as “near misses” where a mistake — such as in the preparation of drugs or equipment — was detected before the patient was treated.

However, in an unspecified number of cases, the patient suffered actual injury or even death.

Officially reported incidents have averaged just over 500 per week since standardised reporting began in January 2004 but the Health Service Executive (HSE) said it was likely only about 30-40% of all incidents were formally logged.

“Sometimes staff members are afraid to report incidents for fear of blame,” said the HSE’s head of quality and risk, Edwina Dunne. “One of our core responsibilities will be to develop within our services a healthy approach to reporting whereby the better we report, the better we learn, the better we become.”

The figures emerged from the data base of the State Claims Agency which handles compensation claims taken by patients against public hospitals. All incidents are supposed to be reported to the agency in case a claim is subsequently made. Of 77,174 incidents reported between January 2004 and September 2006, 1,663 have so far resulted in claims.

Dr Ailis Quinlan, head of the agency’s clinical indemnity scheme, said the data base had only recently been rolled out nationally but from next January, the full figures would be available and would be updated every three months and made public on its website.

“If we become aware of a serious incidents, one of my team of risk advisors will meet with the hospital involved in order to prevent the same situation occurring again,” she explained.

She added that while each hospital’s records were confidential, any hospital could request information from the data base to show how it was performing relative to other hospitals in any individual discipline.

The HSE, which also has access to the data base, said it would be using the statistics to identify trends and recurring problems. “This means that lessons learnt from experiences in one part of the country can now be shared with all parts of the country,” said Ms Dunne.

The HSE also said it was considering the possibility of setting up a Patient Safety Agency, to which patients and medical professionals could report problems and which could order investigations if necessary.

Patients rights group, Patient Focus, said it would back the establishment of such a body. Coordinator, Sheila O’Connor, said: “There is resistance from some sections of the medical profession to this kind of monitoring but I would call on them to support it for the sake of their patients and their professions.”

The Irish Patients Association urged patients who had suffered a mishap in hospital to check with the State Claims Agency that the incident had been reported. The association’s chairman Stephen McMahon, said: “The challenges are to disseminate the lessons from such reports to ensure a culture of vigilance among workers regarding patient safety.”