Single body should track health system mishaps, Hiqa says

Responsibility for collecting information about mishaps and errors in the health system should be given to a single independent body, the State’s heath watchdog has recommended.

The Health Information and Quality Authority (Hiqa) says services must share and act on information about patient safety incidents, and learn lessons to prevent similar incidents happening again.

The authority has published 10 recommendations for the Minister for Health on improving the coordination of patient safety intelligence in order to improve standards.

These include the proposal for a new model for coordinating patient safety intelligence and the implementation of the national incident management system.

Hiqa says a “just culture” needs to be embedded in services to ensure the timely review of information about incidents and to learn from such incidents locally and nationally.

Improve

Introducing the recommendations would help with the identification of risks and greatly improve patient safety, said Dr Kevin O’Carroll, acting director of health information with Hiqa.

“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,” he said. “The diffusion of this information is a lost opportunity to provide early warnings of potential patient safety risks.”

The recommendations, which have been approved by the board of the authority, are prompted by public concerns about the safety of Irish maternity services following a series of baby deaths at Portlaoise hospital. Hiqa reviewed patient safety intelligence systems in Canada, Denmark, England and Scotland as part of its work.

“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,” said Dr O’Carroll.

“This allows the pooling of patient safety intelligence from a range of sources to ensure a more accurate risk profile is identified.”