Call to penalise those who fail to report medical errors
The Tipperary mother-of-three, who was wrongly given the all clear for breast cancer, said there must be a robust system of mandatory reporting of medical errors and unsafe situations to an independent body and to any affected patient.
Ms O’Malley told members of the Irish Healthcare Risk Management Association at their annual conference in Dublin yesterday that attaching a penalty to the failure to report would bring about a much needed culture change.
“It would help remove that agonising moral dilemma, traditionally shared by those who have unfortunately made serious errors and those potential whistleblowers who struggle to report an incident they have witnessed,” she said.
An ingrained health service culture of not looking for, or facing up to mistakes, caused untold hurt to patients and families affected, she said. “It needs to be accepted that one of the best ways to make our healthcare system safer is to welcome each instance of something going unexpectedly wrong, or each unsafe situation as an opportunity to learn and improve.”
She knew of one situation where a radiologist, after completing his day job, was asked to travel across the country to work reading X-rays stacked on the floor of another hospital.
And, she said, if the radiologist did make a mistake, it would be reasonable for the patient to expect the factors contributing to making the error to be reviewed and solutions addressed.
However, the experience of many patients was that requests for information were dealt with in a tortuous manner. It was only the most persistent and determined who were able to overcome the barriers put up by the system and secure a satisfactory response.
The head of a National Health Service watchdog in Britain said its decision to publish patient incident data earlier this year was helping to embed a strong patient safety culture in all NHS organisations.
The National Patient Safety Agency began recording patient safety incident reports in 2003 and in March of this year began publishing the data to increase awareness of patient safety and better reporting.
Chief executive Martin Fletcher said that not publishing the data made it appear secretive and unhelpful. “Secrecy never really works because you just end up looking bad,” he said.
The agency believes that an organisation with a high reporting rate was more likely to have a strong commitment to patient safety and high safety standards.
