Patient Safety

Patient safety is a priority for our health care system. Our vision for patient safety is that all patients receive the safest possible care.

This means

making patients partners in their care,
promoting an open and transparent patient safety culture, and
learning from near misses and mistakes

No patient expects to be harmed in health care. We all expect and hope that our treatment and our family’s treatment or care will be successful and safe. Yet we know that in health facilities all over the world, patients do suffer harm and it is sometimes avoidable. We must do all we can to minimise risks to help avoid patient safety problems

We are making progress in lots of areas. We have implemented many patient safety initiatives in recent years resulting in measurable improvements. Many of these have been in response to serious patient safety incidents.

Some of these initiatives include

Patient Safety Strategy 2019 to 2024

In Ireland, as many as 1 in 8 patients suffer harm while using healthcare services. Maintaining the highest levels of safety is a fundamental priority for Board of the HSE. Launched in December 2019 was the first Board Patient Safety Strategy.

Since then, the Patient Safety Programme are engaging with services and staff throughout the HSE. This is to put in place the objectives and the commitments of the Strategy. They have:

Engagement with Patients and Patient Representatives
Initial communication and engagement with Community Healthcare and Hospital Group Management Teams and QPS Staff
Commencement of a project to develop a Patient Safety Knowledge and Skills Guide
Commencement of a project to develop strategies and processes for patient safety surveillance
Collaboration with leads for each of the thirteen Patient Safety Priority Areas to develop a cohesive approach to improving patient safety and to the funding of patient safety improvements
Progression of the recruitment of 26 QPS Staff as per the Service Plan 2020
Inclusion of the Patient Safety Strategy in to the forthcoming Corporate Plan

Some of the actions in the Patient Safety Strategy are:

To develop a patient safety culture throughout the organisation that is fair and open
Implement and enhance governance structures that improve accountability at every level of the organisation with patient safety as the core focus
Establish a National Patient Safety Programme within the office of the Chief Clinical Officer
Improve systems and processes that listen to, engage with and involve patients in their own care, and in the design, delivery, evaluation and improvement of health care services.
Involve staff in the identification and improvement of patient safety issues including reporting of incidents, learning from the causes of incidents, and learning from examples of good practice and successful initiatives
Improve the capacity and capability of the organisation for patient safety, including supports, resources, education and training, and patient safety surveillance systems and methodologies
Publishing the strategy is another important step toward reducing incidents of patient harm in our health service. The next step in this process is looking at how the strategy will be implemented across the organisation

Read a summary of the Patient Safety Strategy

Read the full Patient Safety Strategy 2019 – 2024

Implementing the strategy

The newly established Patient Safety Programme will identify and build on excellent patient safety improvement work already being undertaken throughout the HSE and has already commenced work on implementation such as developing a high level implementation plan and a communications plan in addition to engaging with various stakeholders throughout the service. The Patient Safety Programme will commence a consultation process which will seek how best to support services in implementing the strategy.

Next steps to roll-out the implementation of the strategy:

Establish governance structures to support the Patient Safety Programme and the implementation of the Strategy
Plan out the approach that will be taken for implementation
Develop a communication and engagement strategy to align with implementation
Involve patient and staff in the implementation planning
Begin a service mapping and gap analysis
Identify strategies, supports and resources need to enhance capacity and capability
Develop the Five Year Patient Safety Strategy Implementation Plan
Advance patient safety improvements within prioritised patient safety areas

Examples of Patient Safety Improvement Initiatives

Across the Irish healthcare system there is strong commitment to improving the safety and quality of care. The National Clinical Programmes are central to improvements to the safety and quality of healthcare delivery. Patient safety and quality improvement initiatives are being implemented across the organisation including.

The Quality Assurance and Verification Team patient safety initiatives include:

A project to promote shared learning following patient safety incidents
The development of Patient safety Stories
Let’s Discuss Programmes
Publication of Complaint Casebooks

The National Quality Improvement Team are co-designing and providing support to apply sustainable improvements in many of targeted safety areas including:

The Pressure Ulcer to Zero and Falls Collaboratives
Deteriorating patient e.g. QI Learning set with Mayo University hospital and Mercy Cork
Medications safety e.g. further roll of Know Check Ask Campaign to encourage people to keep a list of medicines
QI for Health Care Boards The National Quality Improvement Team
Commencing in 2020, QI partnerships in the areas of Frailty, Ambulance services and Health Care associated infections

Support for services

A Strategy for Change

To support and monitor the implementation of the Strategy, a Patient Safety Programme and Team have been established. Patient Representatives will be involved at all stages of the Programme. Patient safety improvement actions will be contained in our National Service Plan and service level Operational Plans. The Patient Safety Programme Team will provide leadership, oversight, co-ordination and monitoring of the implementation of the Strategy.

More information

Contact the Patient Safety Programme

Dr. Cate Hartigan, Lead Patient Safety Programme, cate.hartigan1@hse.ie
Dr. Samantha Hughes, Project Lead, Patient Safety Programme, samantha.hughes@hse.ie
Dr. Sean Denyer, Patient Safety Programme, sean.denyer@hse.ie

Quality Assurance and Verification, Office of the Chief Clinical Officer

Health Service Executive, Dr. Steeven’s Hospital, Dublin 8, DO8W2A8

Phone:01 6352619, national.qav@hse.ie

How we can play our part to improve patient safety?

Engage patients as partners in their care
Involve patients in the design, planning and delivery of our health service
Communicate clearly with patients about their care
Speak up if you see something unsafe
Introduce yourself to patients and their family
Mind your personal health and wellbeing and look out for colleagues who need support
Improve the culture of your workplace by practising the 9 behaviours of Values in Action
Clean your hands properly when caring for patients to reduce risk of infection
Recognise, highlight and build on existing good patient safety practice in your workplace
Improve the quality and timeliness of incident reviews and learn from patient safety incidents
Know about the commons harm that happen in your clinical workplace
If you lead a team, create a secure environment for people to discuss their concerns
Keep good patient records and notes
Talk to patients about any changes to their medicines or care and encourage them to keep an up-to-date list of the medications they are taking