Ireland Case Study

6.2.2 Ireland’s patient safety journey

Ireland’s HSE published its first Patient Safety Strategy in 2019. The five-year strategy set out six commitments:

• empowering patients
• empowering staff
• anticipating and responding to risks
• reducing common causes of harm
• using information to improve safety
• and 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:

Striking the right balance

There is an ongoing challenge to ensure that new initiatives to improve safety do not inadvertently make it harder for people to speak up about safety concerns or hinder the creation of psychological safety. A balance must also be struck between responding to immediate safety failures and maintaining action on longer-term priorities – something that can be difficult to achieve in a politically charged and often litigious system:

6.2.4 What next?

Building on the foundations of Safety-I

Work is ongoing to ensure the foundational elements of patient safety, referred to as Safety-I, remain up-to-date, effective and reflective of evolving patient expectations.

There is, for example, work underway with patient advocates to improve the incident management system, where reviews are perceived as taking too long or where people feel that they have not been involved. The complaints process is also under review to address the “management bureaucracy” behind it to meet Ireland’s ambitions around cultural change:

The HSE’s Patient Safety Strategy will shortly be refreshed, to reflect the regionalisation of the health system under the reforms, the emergence of innovations and technological developments in healthcare, and the publication of the WHO’s Global Patient Safety Report.

Developing an 'end-to-end' system

Work has already taken place to develop a more integrated approach to quality and safety. This includes, for example, bringing together the Quality Assurance and Quality Improvement functions within QPS. Consideration is being given to further develop a systematic approach to safety and quality that links risks, learning from incidents, and improvement work. It draws on ideas from Safety and Quality Management Systems (see box below).

A safety management system (SMS) is a proactive approach to managing safety, integrated into an organisation’s day-to-day business. It incorporates four key elements: safety policy, risk management, assurance, and safety promotion.
A quality management system (QMS) incorporates similar principles and activities to a SMS. It is described as a coordinated approach to planning, improving, controlling and assuring high-quality care across an organisation.
Both approaches– like other frameworks for managing safety and quality – rely on collecting and using data through a philosophy of continuous improvement.

Such a system would support the improved collation and analysis of data to detect areas of risk, as well as identify areas of improvement. This would enable them to “close the learning loop”, thereby developing a more strategic view on broader safety and quality issues:

This increased focus on collecting and using data ties into the journey Ireland has been on since the Covid-19 pandemic to digitise care, to take advantage of a new patient app, and to have electronic patient records give patients access to a single, shared record.