On 5th December 2019 , The Minister for Health in Ireland published a new patient safety bill that will regulate many important measures related to safety initiatives. Included in the bill is legislation that establishes:
• A framework for robust and open disclosure of safety events
• Processes for designating which patient safety incidents will need to be disclosed openly
• National learnings from serious events to support improvements across the country to prevent harm to patients in the first place
This bill is incredibly important and is in line with many of the patient-safety initiatives happening around the globe. In fact, this bill captures how to improve the next generation of patient safety as we move past the previous initiatives that could only get us so far, but never really achieved a true reality of better, quality healthcare.
The Guardian published a story that in the United Kingdom, in the past year, there were 4,600
deaths related to patient safety events. The types of safety events noted—problems with medications, care given, infection control and issues with staffing levels—are not common only to the UK.
These safety incidents frequently occur all over the world. Something positive that was also reported is that it may not necessarily be the number of errors that are increasing, but the number of reported incidents is increasing.
And that’s a start. But to achieve what the Minister for Health in Ireland wants to accomplish with the new safety bill, the healthcare industry in general will need to embrace many initiatives. In the past 20 years, we have gone from paper to digital safety records, and in order to achieve the Minister of Health’s goals, the future state of patient safety will require coordinated technology, information systems and best practices to be successful.
Open Disclosure of Incidents
There’s a legal requirement in the UK—Duty of Candour (DoC)—that requires every healthcare professional to tell patients (or family members) when something went wrong, apologise, offer appropriate remedy and explain short- and long-term effects.
In Northern Ireland and regarding DoC, there are initiatives and requirements concerning disclosures of safety incidents and near misses to patients. With this new patient safety bill, we’re seeing further movement across Ireland, and policymakers looking to each other for some direction as well as providing leadership.
Given current country-wide initiatives, health system and government leaders are understanding the importance of disclosing safety incidents in an “open” and supportive environment. What’s important to note here is that incidents are required—and encouraged—to be recorded in a system that learns from the reports so the incidents don’t happen again.
The environment for reporting should not be punitive, but that does not mean that corrective actions should not be taken.
Organisations should have systems in place for reporting adverse incidents and near misses. There should also be policies that govern how those incidents are reported.
By governing—how, when and why incidents are reported—organisations can take reported incidents to the next levels of learning and incorporate data and mechanisms for effectiveness. That data and information then needs to be proactively shared at every level within the organisation so care teams can incorporate them to reduce harm and promote safety.
The emphasis on an open environment for learning is also important to note in the announcement of the bill and the Minister of Health’s comments. Peers should be able to connect to solve safety issues, in an open community that shares best practices and solves problems. Learning should also incorporate sharing best practices—and having easy access to them.
An important part of reporting and learning from incidents is the ability for team members within various organisations to collaborate. Here is where technology becomes increasingly important because it allows easy retrieval and exchange of information to increase initiatives.
Hospital leaders and policymakers understand the necessity for learning and collaboration, especially as technology has emerged and advanced over the last few years. By incorporating these elements into information systems that the organisation has already invested in, they will soon be on their way to better patient safety.
A recent report by the World Health Organization pointed out that globally, medical errors still harm 40% of patients in primary and outpatient care.
The good news, though, is that we are seeing increased emphasis on patient safety initiatives across many nations. This recent introduction of legislation in Ireland is another example that health system leaders and policymakers are working together to ensure the safety of the healthcare their citizens receive.
One of the most important quotes in the bill’s announcement was that the legislation seeks to support a country-wide focus on creating a just culture through openness, honesty, constant improvement and shared learning. In Ireland, when this legislation is enacted, it will have made a huge leap forward, and hopefully, other countries, leaders, legislators and policymakers will follow.