The HSE and the State Claims Agency today, (October 9th 2012) published details of the number of adverse events reported by hospitals and community based healthcare facilities in 2011. The State Claims Agency works with the HSE to record and analyse adverse events that are reported in the healthcare system.
Recording adverse events and examining why and how they happened is an essential part of promoting a patient safety culture. It supports investigation and information for patients and their families, gives services an opportunity to analyse trends and continuously improve, and informs future planning of health services.
In Ireland, adverse events reported to the State Claims Agency range from near misses, where no harm was caused, to delays in access to services, to damage to a patient’s health and well-being. A total of 85,918 adverse events were reported in 2011. This is across a healthcare system which has in the region of 4.5 million patient contacts a year.
Some new categories of reporting, covering non-clinical personal injury were included in this 2011 data for the first time, which explains the overall increase in reports between 2010 and 2011. Examples of these types of adverse events include trips or falls in a car park or road traffic injuries involving HSE vehicles. Excluding this new category and comparing like with like, the profiles of adverse events reported is steady from 2010 to 2011.
Dr Phillip Crowley, HSE National Director of Quality and Patient Safety, said; “Healthcare organisations with a high level of reporting ofadverse eventshave a better patient safety profile than those that report less. There is now clear evidence of an enhanced culture of reporting within the HSE and the wider health service.Publishing this information is part of our ongoing work to address patient safety issues in an open and transparent way.”
“International data suggests that approximately one in ten hospital in-patients will experience some harm during their treatment and the report published today is in line with incident reporting statistics internationally. While there will always be risks associated with providing healthcare, an open and transparent approach to dealing with adverse events when they arise and a commitment, at every level in the system, to ensuing that patient safety is the number one priority, is part of actively managing the risks and ensuring a quality service for patients.”
Ciarán Breen, Director of the State Claims Agency, said; ‘Risk management is a core function of the Agency. We share our learning and are engaged in a number of joint initiatives with the HSE, including moving towards open disclosure, care of the deteriorating patient and providing system analysis training. By working jointly, both organisations can achieve maximum effectiveness in terms of patient safety.’
‘An example of improvement linked to this partnership is Healthcare Associated Infection, which was identified as a significant issue over the last number of years. The HSE responded by putting a wide ranging infection control programme in place, and the 2011 statistics and the current reporting trends reveal a significant fall off in the number of events involving non-compliance with infection control procedures (see Fig 1.3). The adverse events reporting system is one of the invaluable tools available to track these important trends.’
Fig 1.3 Specific type of event: non compliance with infection control procedures
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‘Another example of improvement is the implementation of an Early Warning Scoring system to help detect rapid deterioration in hospital patients. This was initiated in 2011, currently 25 acute hospitals are using the national early warning scoring system and we are working hard to ensure that the remaining acute hospitals are using it before the end of the year. Preliminary results at an acute tertiary site indicate a 25% decrease in the rate of cardiac arrests in relevant patients’.
Slips, trips and falls are by far the most common adverse events that occur in a healthcare setting, and account for 32% of all adverse events reported in 2011. The impact of a slip, trip or fall can vary from a minor cut or bruise to more severe implications. Healthcare services have a range of policies in place to minimise slips, trips and falls, focusing strongly on staff training. Patient mobility assessments are carried out and assessments of the physical environment to take account of the impact of lighting and access to stairwells for example. The impact of medication on a patient’s mobility is also considered.
Medication errors account for 8% of the adverse events reported. The impact of such errors vary, with some having little or no effect on the patient, while in other cases the effect can be far more severe. The HSE has established a Medication Safety Programme to help reduce medication errors. The programme is working to encourage healthcare professionals to be vigilant for allergies and to give advice on how to prevent inadvertent administration of allergens.
The HSE has in place systems to identify, report, investigate and address adverse events that arise in the delivery of healthcare services. Protocols ensure that any incidents of harm are investigated locally, that issues are identified and actions taken to ensure any risk is reduced. Staff across the HSE have been trained to ensure that all local investigations follow the agreed HSE’s Investigation Procedure and service users often participate in investigations to ensure that the view of the patient is clearly represented at every stage. The outcomes of investigations always include recommendations for risk reduction and improvement, both within the original service, and for dissemination across all similar services.
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