Medical errors must be reported but detail kept private

REPORTS OF serious medical errors and incidents in hospitals which have caused harm to patients should not be made public, Dr Deirdre Madden, chairwoman of the Commission on Patient Safety, has said

Speaking at the launch of the commission's report yesterday, Building a Culture of Patient Safety, Dr Madden said reporting of "serious adverse events" to a new national agency should be made compulsory.

However, she said the details of incidents, including the names of the medical professionals involved, should not be made public and should be exempt from disclosure under the Freedom of Information Act.

The commission's report, recommends that patients who are the victims of medical mistakes should be fully informed of what has occurred and how they have been affected, but that legislation should be introduced to stop this disclosure from being used in any legal action against the practitioner or medical facility.

Through its analysis of reports of medical or administrative errors and poor treatment of patients, collectively termed "adverse events", the commission had identified a medical system lacking clinical leadership, with poor working arrangements between clinicians and management and a lack of incident reporting, Dr Madden said.

Mandatory reporting of serious medical incidents had to be introduced because the voluntary system had resulted in under-reporting in the past, she said.

A new national agency would collate and analyse incidents and disseminate information through the medical system to ensure lessons were learned. The agency could, through annual reports, give information on the types of events that had occurred, but not specific details. "What we would envisage is whatever agency is given the power to do this would disseminate information also to the members of the public, obviously without identifying where the event took place because that's not necessary."

Legislation should be put in place to stop anyone from accessing information on hospital mistakes or accidents, she said.

"There should be exemption from Freedom of Information and legal discovery except where referrals to one of the professional regulatory bodies or the Garda Síochána is required by virtue of the adverse event that has taken place," said Dr Madden.

Patients and their families had suffered and harm had been caused because of their treatment in hospitals, she said.

It was essential that the recommendations of the report be implemented to ensure such incidents were avoided as much as possible in the future, but in the event that patients were caused harm, they should be made fully aware. However, she said, professionals had fears in relation to the information they gave to patients.

"We are aware that there is in the system a fear of litigation arising as a result of, or possible consequence of, disclosure and this can inhibit healthcare professionals and organisations from effective disclosure and communication with patients following an adverse event."

"We recommend that there should be legal protection for open disclosure with patients following an adverse event," she added. "Our overriding principle is that patients are entitled to expect honest and open communication with them in relation to adverse events that may have caused them harm."