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Found 54 results
  1. Content Article
    The National Quality and Patient Safety Directorate (NQPSD) is a team of healthcare professionals working within the national Health Service Executive (HSE) Ireland to improve patient safety and quality of care. They work in collaboration with Health Service Executive operations, patient partners, healthcare workers and other internal and external partners. Their work is guided by the Patient Safety Strategy 2019-2024. 
  2. News Article
    Legal costs in Irish medical negligence cases are among the highest in the world, according to a report that says the slow pace of legal actions here is damaging patients and doctors’ mental wellbeing. The average cost of a legal claim for medical negligence in Ireland is almost three times higher than in the UK, and cases take over 50 per cent longer to resolve, the industry report says. Patients and doctors in Ireland are dragged through what can be a brutal process, for longer than necessary, with patients having to wait longer to receive compensation, the report by the Medical Protection Society (MPS) asserts. In the report, the society, which provides indemnity cover for 16,000 doctors and other healthcare professionals in Ireland, compared the length and cost of legal actions here with other jurisdictions in which it operates. A medical negligence claim in Ireland takes 1,462 days on average (four years), 14% longer than in South Africa and 56% longer than in Hong Kong, the UK or Singapore, it found. Two hundred doctors in Ireland were interviewed for the report: 88% said they were worried about the length of time the litigation process was taking and 91% were worried about their mental wellbeing while it was ongoing. Some said they needed professional help, experienced suicidal thoughts, or quit medicine as a result of the claim. “It was horrendous. I had to leave medicine after it,” says one doctor involved in a claim who is quoted in the report. “I developed severe anxiety during the course of the claim and PTSD. I lost my career in medicine and I am devastated about that. I knew I could never go through the same again.” Read full story Source: The Irish Times, 31 January 2024
  3. News Article
    At least 38 babies died in the space of nine years after serious incidents in the country’s maternity units, it has emerged. The total is based on research of both media reports of inquests and settled claims. Before Christmas, a review by the Irish Examiner revealed 21 hospital baby deaths followed one or more serious incidents, between 2013 and 2021. However, further study in the same nine-year period shows the toll to be higher. The worst year was 2018, when not only did at least 10 babies die, but three of them died at the same Dublin hospital over a five-month period. In at least 18 of the 38 deaths, issues around foetal heartbeat monitoring (CTG) were raised either at inquest or in the High Court. At least 18 of the inquests resulted in a verdict of medical misadventure. As well as issues around heart monitoring, the Irish Examiner review shows that in at least seven of the 38 cases, maternity staff missed signs that a woman was in labour, leading to repeated recommendations around training. In at least seven cases, mothers’ concerns were ignored. Read full story Source: Irish Examiner, 29 December 2023
  4. Content Article
    In May 2021, the Irish public health service was the target of a cyber-attack. The response by the health service resulted in the widespread removal of access to ICT systems. While services including radiology, diagnostics, maternity and oncology were prioritised for reinstatement, recovery efforts continued for over four months. This study describes the response of health service staff to the loss of ICT systems and the risk mitigation measures introduced to safely continue health services. It also explores the resilience displayed by frontline staff whose rapid and innovative response ensured continuity of safe patient care.
  5. Content Article
    The Health Service Executive (HSE) is a large organisation of over 100,000 people, whose job is to run all of the public health services in Ireland. The HSE manages services through a structure designed to put patients and clients at the centre of the organisation. 
  6. News Article
    More than 3,000 patients have died following incidents in the Irish health service since 2018, new data shows. New HSE data shows more than 480,000 incidents potentially causing harm were recorded across hospitals and community healthcare groups since 2018. These include falls, attacks on patients or staff, problems with medication, treating the wrong limb, or reactions to medical devices, among other issues. Last year’s total of 106,967 was the highest of five years recorded, up from 94,422 in 2018. While around half the incidents annually led to no injury, last year 0.65% or 556 led to a death. That stood at 0.59% or 557 deaths in 2018. A spokesperson for the Irish Nurses and Midwives Organisation (INMO) said the figures are very high, but not surprising. “Hospitals are not supposed to be dangerous places," she said. "No matter how highly skilled your staff are, patient safety issues and the risk of missed care incidents are inevitable in a situation where patients are lining corridors on trolleys and there aren’t enough staff to care for them." Read full story Source: Irish Examiner, 18 August 2023
  7. News Article
    The number of notified “extreme” and “major” incidents involving serious harm to patients and others in hospital has risen significantly in the Republic of Ireland in recent years, new figures reveal. Reported “extreme” incidents, which can involve death or permanent incapacity, rose from 373 in 2017 to 579 last year. The number of cases classified as “major”, where there is long-term disability or incapacity, climbed from 46 to 82 in the same period. “Moderate” incidents, when there is a patient injury involving medical treatment, also increased from 9,219 in 2017 to 13,563 last year. Minor incidents, involving injury or illness needing first aid, also increased over the same time from 9,210 to 15,483. The figures, involving patients, staff, visitors, contractors and the public, were released by the HSE in response to a parliamentary question from Aontú leader Peadar Tóibín. A spokewoman for the HSE said: “It is HSE policy that all incidents are identified, reported and reviewed so that learning from events can be shared to improve the quality and safety of services.” “The number of reported incidents has increased year on year since 2004 with a significant increase noted since 2015, with the introduction of the National Incident Management System.” Read full story Source: Independent.ie, 3 May 2022
  8. News Article
    At least 200,000 people missed out on essential surgery as a result of the Covid-19 pandemic, with many enduring “misery and daily pain” as a result, a conference has heard. Both scheduled and emergency surgery levels dropped by 20% during the pandemic, suggesting there is now significant pent-up demand for treatment, according to the national clinical lead in surgery, Prof Deborah McNamara. Almost 343,000 people are waiting to see a surgeon for the first time, 100,000 of whom have been on a waiting list for more than 18 months, she told the conference on outcomes from the pandemic at the Royal College of Surgeons in Ireland (RCSI). This was only the start of delays for patients, she pointed out, as they have to wait again for their procedure to be carried out. Currently, more than 71,000 patients are waiting for surgery, a fifth of whom have been on the list for more than a year. Long-waiting patients needing complex surgery have been disproportionately affected, she said, as the system focused on treating “quick-win” procedures such as endoscopies. The amount of day-case work carried out by hospitals is back to 84 per cent of 2017 levels, yet complex care remains at only 67 per cent, she pointed out. Patients waiting for surgery were enduring a “huge amount of misery” that remains unquantified, according to Prof McNamara. The pandemic resulted in some positive changes, she said, including shorter hospital stays, a greater role for physician associates and a generational change in the use of IT. However, it also led to greater constriction in the capacity for scheduled surgery, and greater seasonal variations in demand. Read full story Source: The Irish Times, 26 April 2022
  9. News Article
    A phone first system adopted by most GP surgeries at the start of the pandemic is "here to stay", the Royal College of GPs (RCGPs) in Northern Ireland has said. However, the RCGP has also accepted patient access needs to improve. The system was introduced in spring 2020. According to GPs, the move, which came without either consultation or prior information, was necessary to minimise the risk of infection of Covid-19. Two years on, there is concern among some members of the public that the system is not working. Speaking to BBC News NI, Dr Ursula Mason accepted that the system wasn't working but said there were not enough GPs to see people. She added that the telephone system, which was being "refined" and "improved" was the best way to manage "growing demand" and to "prioritise the sickest patients to be seen first". "The telephone system allows us to see many more patients, to deal with demand in a better way so I think the telephone system is here to stay," added Dr Mason. "There will be some changes to upgrade it, but it will form a significant part of how we manage demand."
  10. News Article
    Patients in nine hospitals in Ireland were often treated in the wrong places, sometimes corridors, in situations where it was “unclear” who was supposed to be providing their care, a clinical review has found. It warned of the potential for people to receive inappropriate specialist input and recommended specific wards be used to avoid so-called “safari rounds” where consultants must seek out scattered patients. The independent review team consisted of clinical and management experts from Scotland and England who undertook a programme of visits between August and November, 2019. “The review team witnessed widespread boarding and outliers – any bed, anytime, anywhere and including mixed gender,” the document said. “This does not create extra capacity, leads to safari rounds, increases length of stay, introduces harm by non-specialist care and increases staff absenteeism.” Although acknowledging often excellent work by staff, the report was commissioned to examine non-scheduled care at nine hospitals found to be “under the greatest pressures” during the winter season of 2018/2019. These had “significant numbers” of patients waiting for long periods on trolleys. Read full story Source: The Irish Times, 4 April 2022
  11. News Article
    More than 200 women were affected by failures in Ireland’s CervicalCheck screening system. It emerged in 2018 that 221 women and families were not told about misreported smear tests. The Minister for Health said that non-disclosure issues which arose in the cervical check screening controversy will be legislated for to prevent it from happening again. Stephen Donnelly said new legislation will address the negligence issues and ensure that the failure to inform the women of the clinical audit of their screening will “never happen again”. Mr Donnelly was discussing a number of amendments at the committee stage of Ireland's Patient Safety Bill. The new legislation will require the mandatory open disclosure of serious patient safety incidents, and sets out a list of incidents which must be reported to the health watchdog, Health Information and Quality Authority (HIQA). Mr Donnelly said that he will introduce an amendment at the report stage of the Bill that will provide for non-disclosure and will deal with issues around delayed diagnosis and delayed screening. Mr Donnelly said: “I’ve had lengthy discussions with the department on this and it doesn’t fit neatly with this Bill because the serious patient safety issues which result in death or serious harm, they are very clear and binary. “Legislating around delayed diagnosis and delayed screening, it is really complex and doesn’t fit neatly in this Bill, however my view is that the non-disclosure that happened in cervical check, even though it doesn’t neatly fit here, should still be legislated for." Read full story Source: The Independent, 11 March 2022
  12. News Article
    Urgent action is required to tackle hospital waiting times on both sides of the Irish border, according to the Economic and Social Research Institute (ESRI). A report into the primary healthcare systems of Ireland and Northern Ireland found that both jurisdictions are experiencing similar problems. These include workforce shortages and increasing expenditure. On hospital waiting times the problem is worse in Northern Ireland. The proportion of people on the waiting list in Northern Ireland for more than one year increased from 20% to 60%. In the Republic of Ireland, during the same period between 2017 and 2021, the figure increased from 12% to 20%. A key distinction between the healthcare systems is the absence of a universal healthcare system in Ireland, write the authors. That means in Northern Ireland, all residents are entitled to a wide range of free health care services, while in Ireland, the majority pay to see their GP and for other services. But despite this key difference, both systems are currently facing similar challenges, including shortages in key areas of the workforce and long waits for a range of healthcare services. Cross-border collaboration in healthcare across the island is an interesting but contentious issue. At present, according to the ESRI report, that work is relatively limited. It points to a 2011 report which identified the potential benefits to be gained from increased co-operation in healthcare including collaboration in cystic fibrosis, ear, nose and throat surgery, paediatric cardiac surgery and acute mental health services. However, this 2022 report concludes that despite some notable exceptions such as the Congenital Heart Disease Network and the North West Cancer Centre at Altnagelvin Hospital in Londonderry, "collaboration has been relatively limited". Read full story Source: BBC News, 10 March 2022
  13. News Article
    At least 12,000 people were treated for sepsis in hospitals in Ireland last year, with one in five of those dying from the life-threatening condition. However, the HSE said the total number of cases is likely to be much higher. Marking World Sepsis Day, it said the condition kills more people each year than heart attacks, stroke or almost any cancer. The illness usually starts as a simple infection which leads to an “abnormal immune response” that can “overwhelm the patient and impair or destroy the function of any of the organs in the body”. Dr Michael O’Dwyer, the HSE’s sepsis clinical lead, said: “The most effective way to reduce deaths from sepsis is by prevention. “A healthy lifestyle with moderate exercise, good personal hygiene, good sanitation, breastfeeding when possible, avoiding unnecessary antibiotics and being vaccinated for preventable infections all play a role in preventing sepsis. “Early recognition and then seeking prompt treatment is key to survival. Recognising sepsis is notoriously difficult and the condition can progress rapidly over hours or sometimes evolve slowly over days.” Read full story Source: Independent Ireland, 13 September 2022 hub resources on sepsis RCNi: Sepsis resource collection NSW Clinical Excellence Commission - Sepsis toolkit Dr Ron Daniels video: Recognising sepsis Introducing the Suspicion of Sepsis Insights Dashboard
  14. News Article
    Unfilled specialised medical consultant roles and an over-reliance on overworked, internationally trained graduates for non-consultant hospital doctors are among key risks to patient safety identified by the Irish Medical Council. The council, which is the regulatory body for the medical profession, sets out the risks to healthcare for the first time in its workforce intelligence report that breaks down the make-up of the medical register and explains why doctors are leaving the health system. More than a third of all clinically active doctors are on the general register, which is a key risk to patient safety because consultant and specialist roles are not being filled and “a considerable proportion” of non-consultant hospital doctors are required to perform the duties of consultants. The report found that the majority of non-consultant hospital doctors are trained overseas and that the health system overly relied on these doctors who reported being “overworked, undervalued, experiencing discrimination and unable to access specialist training.” “Aside from the individual impact on the doctors, the treatment of international medical graduates has serious implications for patient safety,” the council said. In another risk identified by the regulatory body, more than a quarter of doctors reported working more than 48 hours a week, in breach of the European Working Time Directive. This has further serious implications for patient safety,” the council said. Read full story Source: Irish Times, 1 September 2022
  15. News Article
    Major concerns are being raised about the Irish State’s failure to set up an inquiry into a drug that caused serious birth defects and developmental delays in at least 1,200 Irish babies. Sodium valproate, a drug used to treat epilepsy and bipolar disorder, has been estimated to have caused major malformations in up to 341 Irish children between 1975 and 2015 after it was taken by their mothers during pregnancy. The drug, which is sold in Ireland as Epilim, is also believed to have caused neuro-developmental delays in 1,250 children. Many women were never warned of the risks that taking the drug during pregnancy would pose to their babies. Read full story Source: The Irish Independent
  16. News Article
    The Irish health services did “relatively well” during Covid-19 but, as in other countries, the pandemic unmasked existing problems, a renowned patient safety expert has said. Peter Lachman of the Royal College of Physicians of Ireland (RCPI), was one of nine international experts who consulted on a new World Health Organization (WHO) report on the implications of the Covid-19 pandemic for patient safety. Dr Lachman said the impact is only starting to be understood. “Ireland did very well early on [in the pandemic], then opened up over Christmas [2020] which led to our numbers going sky-high, then we clamped down again,” he said. "We did well on some things and not so well on others. We have done relatively well when compared with other countries." “Covid-19 was an event which around the world unmasked problems which were there already rather than creating them necessarily,” he said. “The findings start with safety problems — we’ve had safety problems in Ireland but things are getting better. There is a good strategy coming on. I’ve worked with hospitals around the country on this. It’s no worse than other countries.” Read full story Source: The Irish Examiner, 12 August 2022
  17. News Article
    More than one fifth of complaints about Irish hospitals were deemed ‘high severity' including one from a person who claimed their mother should not have died and another who alleged a patient was turned away from an A&E even though she was at risk of self-harming. An analysis of 641 complaints about HSE hospitals between October and December 2019 by NUI Galway and the HSE separated them into high severity (22%), medium severity (56%) and low severity (also 22%). Among those complaints highlighted as potentially linked to ‘catastrophic harm’ was this: “My mother would still be alive if this had not happened." However the largest number were about hospital systems at 392 — including complaints about waiting lists. “I was left on a waiting list for surgery for years,” at least one person wrote. The analysis also found 322 complaints centred around patients’ arrival into hospitals including emergency departments (ED). “She was turned away instead of admitted even though she was at risk of self-harming,” one person wrote. Some 92 complaints related to staff not listening to patients, including new parents who said: "While our newborn son was on the ward they took too long to notice his difficulty breathing and transfer him to the NICU (neonatal intensive care unit)." Read full story Source: Irish Examiner, 11 July 2022
  18. News Article
    Women who underwent damaging surgery in Irish hospitals have accused health authorities of dragging them into a "nightmare" of "gaslighting, ignorance and disrespect". Having had vaginal mesh implants, the women told an Oireachtas committee that they were "maimed" and then led on "a fool's errand" when they sought support from the HSE. The Health Committee heard from members of Mesh Ireland and Mesh Survivors Ireland who represent around 750 women. While the HSE said that it would be "extremely difficult" to provide accurate figures, it estimates that around 10,000 women had this surgery in Ireland. More than one in ten have suffered complications, Dr Cliona Murphy, Clinical Lead for the National Women and Infants Health Programme, revealed. Mary McLaughlin, Mesh Ireland, said that at one point, "I lay in bed 16 hours a day", because of the pain she was in. She demanded dignity and respect for survivors in the face of this "global scandal". The women are calling for access to a US-based expert in complete mesh removal, to mirror schemes in Scotland and the Canadian state of Quebec. Read full story Source: RTE, 29 March 2022
  19. News Article
    A cross-border trial has improved care for patients prescribed multiple medicines. The iSIMPATHY project, funded by the European Union's INTERREG VA Programme, worked with professionals in Scotland, the Republic of Ireland and Northern Ireland to comprehensively review patient medication. Taking multiple medicines can be problematic if the increased risk of harm from interactions between drugs, or between drugs and diseases, outweighs the intended benefits. Interim findings showed these interventions potentially prevented major organ failure, adverse drug reactions, avoided hospital admissions and saw patients moved to more appropriate medication. Scotland’s Public Health Minister Maree Todd said: “This project looked at some of our most vulnerable patients taking more than five medications. The reviews have avoided adverse combinations of drugs and hospitalisations while also reducing prescriptions and drugs costs. “We will know more when the full evaluation is published in June, we will work with partners to see how we can these improvements can be applied more widely, potentially saving lives and money.” Read full story Source: Scottish Government, 10 March 2023
  20. News Article
    High risks relating to the ordering, prescribing, storing and administration of medicines have been found by the Mental Health Commission in a series of inspections of mental health centres in Dublin. The commission emphasised the need to have appropriate practices including the recording of the minimum dose interval information; where medication has been stopped, the stop date to be recorded; and the need to always have the prescriber’s signature recorded. The inspector of mental health services Dr Susan Finnerty said it was positive to see centres maintaining high compliance rating, but spoke of concerns around the administration of medication. “We know that medication is an important tool in treatment of mental illness. In order to reduce the risk of medication errors, we need to be sure that medication prescription and administration records are completed correctly,” Dr Finnerty said. Read full story Source: Independent Ireland, 18 January 2023
  21. News Article
    Patients are not safe from harm in three out of seven emergency departments, a damning new Hiqa inspection report has revealed. The report was released on the same day as an Oireachtas committee was warned of a growing crisis in primary care, with patients in some parts of the country unable to access basic GP services. Emergency Departments in Cork University Hospital (CUH) and University Hospital Limerick (UHL) were among seven EDs assessed by the health watchdog. In three EDs, including Cork and Limerick, inspectors found failures to ensure “service providers protect service users from the risk of harm.” Inspectors also found patients’ “dignity, privacy and autonomy” was not respected in UHL, while CUH was only partially compliant in this area. The report also highlighted lengthy waiting times, including one patient who spent 116 hours on a trolley at UHL. Read full story Source: The Irish Examiner, 15 December 2022
  22. Content Article
    Storytelling gives a voice to patients and staff as well as providing an opportunity for others to understand the importance of patient safety from the perspectives of those that access services or work within them. This toolkit was developed by the National Quality and Patient Safety Directorate in Ireland which works in partnership with health services, patient representatives and other partners to improve patient safety and quality of care. It provides a step by step guide to creating patient and staff stories.
  23. Content Article
    This multinational research study in the journal Diabetes Research and Clinical Practice aimed to investigate perceived to people with diabetes adopting and maintaining open-source automated insulin delivery (AID) systems. 129 participants with type 1 diabetes from 31 countries were recruited online to elicit their perceived barriers towards the building and maintaining of an open-source AID system. The study identified a range of structural and individual-level barriers to the uptake of open-source AID, including: sourcing the necessary components lack of confidence in one's own technology knowledge and skills perceived time and energy required to build a system fear of losing healthcare provider support Some of these individual-level barriers may be overcome over time through the peer-support of the DIY online community as well as greater acceptance of open-source innovation among healthcare professionals. The findings have important implications for understanding the possible wider use of open-source diabetes technology solutions in the future. Further reading How safe are closed loop artificial pancreas systems?
  24. Content Article
    This video from the Irish Health Services Executive (HSE) tells the story of Barry, a paediatric nurse who made a medication error when treating a critically ill baby. Barry describes how the incident and the management response to it affected his mental health and confidence over a long period of time. He also describes how he had to fight to ensure the family were told the full story of what had happened, and the positive relationship he developed with the baby's mother as a result. The baby received the treatment they needed and recovered well.
  25. Content Article
    This video published by the Irish Health Service Executive (HSE) tells the story of Pat, whose bowel cancer diagnosis was missed, resulting in his premature death. His daughter Patricia talks about the two investigations that took place into her father's death and how the hospital's internal investigation failed to acknowledge that a staff member had raised concerns about Pat's initial colonoscopy on five occasions, but this had not been followed up. She describes the impact of these events on her father and the rest of the family and calls on medical professionals to "trust us (families) more and fear solicitors less."
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