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The Quality and Patient Safety Competency Navigator is a self-assessment tool. It will help you identify and develop the key competencies needed to provide safe and quality care. It will also sign-post you to relevant educational resources and learning opportunities. Who can use the QPS Competency Navigator? This resource is for everyone and can be useful for: students to develop skills for safe patient care staff to self-assess competence and identify learning needs line managers to guide professional development conversations healthcare educators to inform the design of learning programmes. patients to learn how they can play a role in supporting quality and patient Safety. How to use the QPS Competency Navigator? The QPS Competency Navigator describes six topics related to quality and patient safety. You can explore these depending on your role. You can use the tool to identify specific knowledge and skills that you need to develop and discover ways to learn more about a topic.

This opinion piece in the Irish Times outlines the results of an independent report into medication errors at Galway Hospice in 2004. The report uncovered medication errors and breaches of the Misuse of Drugs Act (1988) that had resulted in patient harm. It outlines the role of Dr Dympna Waldron, consultant in palliative medicine with the Western Health Board in speaking up to prevent harm to patients from medication errors.

The Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023 was signed into law in May 2023 and came into effect from 26 September 2024. This flyer highlights the key points.

The Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023 (PSA 2023) was signed into law on 2 May 2023. The Act provides for a number of important patient safety issues including: The mandatory open disclosure of a list of specified serious patient safety incidents that must be disclosed to the patient and/or their family. The mandatory external notification of those same events to the appropriate regulatory body. The Act also provides for similar mandatory open disclosure requirements for completed individual patient reviews of their cancer screening by the HSE’s National Screening Service. The extension of the Health Information and Quality Authority’s (HIQA) remit into prescribed private health services and private hospitals. The Act provides the Chief Inspector within HIQA with a discretionary power to carry out a review of certain serious patient safety incidents which have occurred during the provision of health care in a nursing home (this provision will be commenced at a later date following a required technical amendment). The overarching purpose of the Act is to support and further embed a culture of openness and transparency in relation to patient safety within the wider healthcare system, including private healthcare. This guidance document is to assist stakeholders in understanding the provisions of the PSA 2023. 

The Patient Safety (Notifiable Incident and Open Disclosure) Act 2023 (referred as the Act) introduces a legal framework for patient safety, focusing on open disclosure. The Act requires health service providers to report notifiable incidents to the relevant regulator. All notifiable incidents are listed in Schedule 1 of the Act. All health service providers must report the notifiable incident to the relevant regulator using the National Incident Management System (NIMS). HSE and HSE-funded services (Section 38 organisations) will report the notifiable incident directly from the incident management record and private providers will access NIMS using a portal on the relevant regulators website pages. For the purpose of reporting notifiable incidents on NIMS there are some key roles and responsibilities which are outlined in this document.

The Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023 was signed into law in May 2023 and came into effect from 26 September 2024. The Act seeks to strengthen openness and transparency throughout the Irish health care system. It applies to public and private health services and must be followed by all staff. A key focus of the Act is on open disclosure. This video from the Health Service Executive summarises the Act.

The Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023 was signed into law in May 2023 and came into effect from 26 September 2024. Overview of the Act The Act seeks to strengthen openness and transparency throughout the Irish health care system. It applies to public and private health services and must be followed by all staff. A key focus of the Act is on open disclosure. Open disclosure is defined as an open, honest, compassionate and timely approach to communicating with patients and, where appropriate their relevant person, following patient safety incidents. The Act introduces a legal requirement to disclose a list of specific incidents called notifiable incidents. The notifiable incidents are described in the Act. The Act requires health services providers to be open and transparent with patients, their families, or both depending on the patient's wishes. For most of the notifiable incidents the patient has sadly died. The Act outlines a process for open disclosure, ensuring that patients, their families, or both, receive truthful and timely information in any healthcare setting when a notifiable incident happens. The Act also requires mandatory notification of the notifiable incidents to the appropriate regulatory body. Summary of the Act The Act provides a legal framework for: Mandating a health services provider to disclose notifiable incidents when providing a health service to a patient. There are currently 13 notifiable incidents but the Minister of Health may add to this list in the future - Notifiable incidents 1.10 and 1.11, which relate to incidents in maternity and neonatal care, use terminology that has been defined by regulation. This regulation has now been published as ‘Statutory Instrument 501/2024’ and is available on the Patient Safety (Notifiable Incidents and Open Disclosure) Regulations 2024 - irishstatutebook.ie. Mandating health services providers to communicate reviews of cancer screenings they have carried out at the patient's request (breast, bowel and cervical screening). Information shared, as well as an apology made, as part of an open disclosure of a notifiable incident and communication of patient-requested cancer screening reviews, cannot be used for certain legal or regulatory purposes Procedures for clinical audits and protections for the data gathered. A health services provider must inform the relevant regulator (Mental Health Commission, Chief Inspector of Social Services, and the Health Information and Quality Authority) of a notifiable incident within 7 calendar days using the National Incident Management System (NIMS). It is important to note that reporting notifiable incidents through NIMS does not remove the need to report such incidents through other reporting channels. The law outlines the requirement of the designated person, who is a support person for the patient or their relevant person and is an employee of the health services provider. The designated person is essential for open disclosure The Act specifies what should be discussed at the open disclosure meeting and cancer review meetings, in the written follow-up, and how important it is to keep accurate records. Open disclosure is recognised as a process, and the Act specifies what must be covered at an open disclosure meeting, written follow-up of such meetings, the need for additional open disclosure meetings, as well as how a patient or their representative can seek clarification on what was discussed. Once the incident has been logged on NIMS, in line with local governance processes, the health services provider (HSE or S38) can notify the relevant regulator on this digital platform. Private providers and independent practitioners will report a notifiable incident through a portal on the regulator's website. The Act amends Part 4 of the Civil Liability (Amendment) Act 2017 to align the process with that of the Patient Safety Act. It applies to all patient safety incidents but is not mandated in law. It is an option for staff to use it if they would like similar protections that apply to the Patient Safety Act for all other patient safety incidents. Amendments to the Health Act 2007 that modify the threshold for HIQA to carry out statutory investigations and expansion of monitoring into private hospitals. The Chief Inspector of Social Services' discretionary power to carry out a review of specified incidents that may have resulted in death or serious injury where some or all of the care was delivered in a designated centre, such as a nursing home. This part of the Act is not commencing on 26 September 2024. It will commence once an essential technical update has been made to the Act. Commencement of this part of the Act will be communicated by the Department of Health in due course. There are 2 circumstances recognised in the Act where open disclosure may not happen: if the patient or their relevant person declines open disclosure. In this scenario, they must be provided with the information on how to contact the health services at any time within the next 5 years to request open disclosure when the patient or their relevant person cannot be contacted despite reasonable attempts to do so. Clinical audit The Act encourages staff to carry out clinical audits to continuously improve our patient care standards. The Act offers significant legal protections to clinicians undertaking clinical audit . Information created during a clinical audit cannot be used as: admission of fault by a healthcare professional or organisation evidence in legal cases (civil proceedings) against healthcare professionals or healthcare organisations evidence to cancel a healthcare professionals’ indemnity insurance evidence of fault, professional misconduct, poor professional performance or any other failure or omission evidence in disciplinary or fitness to practice procedures against healthcare professionals.

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.

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.  The HSE Code of Governance provides an overview of the principles, policies, procedures and guidelines by which the HSE directs and controls its functions and manages its business, it is intended to guide the Directorate, leadership Team and all those working within the HSE and the agencies funded by the HSE, in performing their duties to the highest standards of accountability, integrity and propriety. Quality and Patient Safety Matters #AllThingsQuality is HSE's quarterly newsletter: Edition 1 April 2023 Edition 2 July 2023

The National Clinical Guideline for Stroke for the UK and Ireland provides authoritative, evidence-based practice guidance to improve the quality of care delivered to every adult who has a stroke in the United Kingdom and Ireland, regardless of age, gender, type of stroke, location, or any other feature. The guideline is intended for: Those providing care – nurses, doctors, therapists, care staff. Those receiving care – patients, their families, their carers. Those commissioning, providing or sanctioning stroke services. Anyone seeking to improve the care of people with stroke. The guideline is an initiative of the Intercollegiate Stroke Working Party.

Preventable adverse events are an ongoing challenge in healthcare. International studies demonstrate that 3%–17% of admissions are associated with an adverse event (defined as an injury caused by healthcare management resulting in prolonged hospitalisation, disability on discharge or death). Approximately half of the adverse events are preventable. Little is known about adverse events in the Irish healthcare system.Therefore, recommendations on improving patient safety at a national level are being made on limited information. The aim of the Irish National Adverse Events Study (INAES) from Rafter et al. was to quantify the frequency and nature of adverse events in acute hospitals in the Republic of Ireland for the first time using an internationally recognised retrospective patient chart review methodology.

Do you know your medicines? Do you keep a list? Can you describe and discuss your medicines with healthcare professionals and family when you want to? Ireland's Health Service Executive's National Medication Safety Programme works with patients to improve the safe use of medicines.

This study, published in BMJ Quality and Safety, aimed to quantify the prevalence and nature of adverse events in acute Irish hospitals in 2015 and to assess the impact of the National Clinical Programmes and the National Clinical Guidelines on the prevalence of adverse events by comparing these results with the previously published data from 2009.Key findings:an estimated 54,000 patient safety or adverse incidents occurred in Irish public hospitals in 2015 this cost the health service an estimated €190m in additional costs for extended hospital stays and treatmentthe volume of adverse incidents in hospitals "remained stable" between 2009 and 201514% of all hospital admissions in 2015 involved an adverse incident compared to 12.2% in 2009.

The Health Information and Quality Authority (HIQA) has published its annual overview report of lessons learned from receipt of statutory notifications of accidental and unintended exposures to ionising radiation in 2020. This report provides an overview of the findings from these notifications and shares learnings from the investigations of these incidents. Further reading HIQA: Annual report of accidental or unintended exposures to ionising radiation in 2019 CQC reports on safe use of radiation in healthcare settings (19 December 2019)