Shocking HSE report reveals surgery blunders

There were 233 serious reportable incidents in Irish healthcare providers over the course of just 19 months, which resulted in 100 deaths.

Shocking HSE report reveals surgery blunders

By Evelyn Ring, Irish Examiner Senior Reporter

Patients dying after being attacked, sexual assaults, deaths during surgery, and an abduction from a hospital feature in a shocking HSE report published yesterday.

The litany of serious incidents in hospitals and other state-run healthcare facilities includes surgery performed on the wrong person, patients with items left inside them after operations, and procedures carried out on the wrong parts of the body.

The HSE report reveals 233 “serious reportable events” were logged over a 19-month period to September this year.

While it was confirmed that, in 100 of the cases, a person had died, the health authority stressed that this did not mean that death was a direct result of the incident.

Serious surgical incidents — there were 23 — accounted for 10% of the mistakes. In three cases, surgery was performed on the wrong body part and, in one case, surgery was performed on the wrong patient.

There were four incidents where a patient with no known medical problems died during surgery or after an operation. There were 19 incidents where death or serious disability was associated with a diagnostic error, such as a mislabelled pathology specimen.

In 54 cases, a patient died or suffered a serious disability as a result of falling in a healthcare facility or during a clinical intervention.

There was one report of someone impersonating a healthcare professional and another where a patient was abducted.

There were 12 reports of patients who were sexually assaulted within or on the grounds of a hospital or healthcare facility — the majority of these were perpetrated by a fellow patient — and seven where patients died or were seriously injured after being physically assaulted.

There were 173 incidents reported by acute hospitals, 28 by mental health facilities, and 30 by social care facilities, with one incident classified as “other”.

The decision to establish a framework for serious reportable events was introduced in March last year and a list of events and a guide was published in January.

The HSE warned, however, that while there is a good history of reporting in many services, there were variations. Some facilities did not submit any reports.

While reporting was improving every month, comparisons could not be made until there was greater confidence about reporting levels.

The health authority said that while excellent care and outcomes were most often the result of interventions, modern healthcare also carried significant risks and, at times, things did not go to plan. “Creating a culture of open disclosure and learning from the things that go wrong is the bedrock of making systems safer,” it stated.

The HSE report said a range of quality improvement initiatives are being implemented across the health system, including:

* The development of Patient Safety Statements for each of the country’s hospitals to monitor quality and safety across these hospitals;

* The establishment of the HSE’s National Women and Infants Programme;

* The development of the Irish Audit of Surgical Mortality in collaboration with the Royal College of Surgeons in Ireland;

* Implementing initiatives outlined in ‘Connecting for Life’, the national strategy to reduce suicide.

You can read the report in full here.

This report first appeared in today’s Irish Examiner.

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