Ireland’s HSE published its first Patient Safety Strategy in 2019. The five-year strategy set out six commitments:
empowering patientsempowering staffanticipating and responding to risksreducing common causes of harmusing information to improve safetyand ensuring strong leadership and governance
These commitments followed on from progress made in building the infrastructure for patient safety in the preceding decade. That journey began following the Commission on Patient Safety and Quality, known as The Madden Review, in 2008.
The Madden Review was tasked with setting out a new framework for the governance of patient safety and quality, following a series of high-profile, serious, adverse events across the country.
The key outputs of the review – including designated officers responsible for safety and quality within organisations – were designed to support a culture of continuous improvement, rather than a short-term, reactionary response to the incidents that triggered it.
In 2016, a National Patient Safety Office was set up to provide “the resource and capability to really drive forward patient safety policy and strategy.”
Based within the Department of Health, the Office is responsible for developing policy (in areas such as antimicrobial resistance) and legislation (licensing of healthcare facilities is next on the patient safety legislative agenda), monitoring performance and conducting surveillance, and publishing reports and guidelines.
The HSE is responsible for the delivery of public healthcare in Ireland. There has been a continued evolution of the structure of HSE’s patient safety activities, which were brought under a single National Quality and Patient Safety (QPS) function in 2021. Core activities within QPS cover incident management, clinical audit, building improvement capability, and using data and intelligence to support improvements.
In the years following The Madden Review, high-profile, serious, adverse events in areas such as maternity and neonatal services, paediatrics and radiology continued to play a key role in shaping and driving Ireland’s patient safety efforts. For example, the tragic death of a young person from sepsis in a hospital in November 2022 prompted a rapid programme of work aimed at improving the early identification and management of sepsis, and in supporting the use of early warning scores in emergency departments.
Openness and transparency with patients and families now underpin Ireland’s patient safety work.
The country’s first-ever Patient Safety Act (2023) set out healthcare organisations’ legal obligations to inform patients and families – and the appropriate regulatory body – when one of a defined list of notifiable incidents takes place.
A National Open Disclosure Framework (2023) seeks to embed the principles of openness in a wide range of circumstances to support broader cultural change across Ireland’s healthcare system.
A range of other policies and interventions are in place that reinforce the principle of open disclosure. These include an incident management framework to create more robust structures for reporting and reviewing adverse events, and for the National Patient Advocacy Service to provide free and independent support to people following an incident.
Between 2015 and 2023, the National Healthcare Quality Reporting System provided publicly available information on the quality of healthcare.
This included indicators focused on “treating and caring for people in a safe environment”, covering areas such as healthcare-associated infections, antibiotic consumption and medication safety.
These indicators have now been integrated into a new Health System Performance Assessment framework which provides an overall view of the performance of Ireland’s health system.
6.2.3 What has been learnt?
Responding to high-profile incidents
Ireland has used the responses to care failings to improve patient safety. This has been driven in part by the high public and political profile of the events, combined with a genuine determination by the Department of Health and the HSE to improve safety “right across the system, not just where they happened”.
As a result, a principle of open disclosure with patients and the public has become the key tenet of Ireland’s work on patient safety, determining the type of policies and initiatives that have been pursued.
It has also meant that the implementation of key aspects of patient safety infrastructure has been accelerated, receiving significant political support and resources. Helpful to this agenda in recent years has been the support of ministers who understand the issues, who are supportive of efforts to enhance the patient experience, and who are committed to making the system as transparent as possible: