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News Article
The Irish Health Service Executive (HSE) is set to spend up to €50m on a new national electronic prescription service as it seeks to modernise as part of Ireland’s “broader digital health transformation”. It has gone out to tender for the provision of this technology which it said will be rolled out in both public and private settings across the country’s healthcare system. “Ireland’s healthcare system currently lags behind other European countries in its adoption of digital technologies,” it said. “Its prescribing and dispensing processes are fragmented, with either Healthmail (secure email) or paper-based prescriptions being used. Healthcare providers often lack timely access to a patient’s complete medication history, leading to errors, communication gaps, and inefficiencies. Patients also have limited access to their medication information.” The current “healthmail” system has several limitations, according to the HSE, such as community pharmacy staff needing to locate and open patient files on the dispensing system and then transcribing details from prescriptions when they’re dispensing it. The HSE said the new prescription service will be secure, efficient and a fully integrated digital service to transmit and store electronic prescriptions and dispensations for patients. It will also integrate with existing and future health platforms and allow prescribers to generate prescriptions for patients electronically. “It will enable accurate, timely access to medication information, which will enhance clinical decision-making, reduce medication errors, streamline clinical workflows, empower patients and improve overall patient care,” it said. Read full story Source: Irish Examiner, 25 May 2025- Posted
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A hospital doctor has admitted professional misconduct over an incident in which a patient with meningitis suffered a fatal lack of oxygen to the brain following a dispute with nursing staff over whether a breathing tube had become dislodged. Ilankathir Sathivel appeared before a medical inquiry to face a series of allegations over his treatment of a patient in February 2019 while working as a registrar anaesthetist at Connolly Hospital Blanchardstown in Dublin. The hearing before the Medical Council’s fitness-to-practise committee was told Dr Sathivel was making a number of admissions in relation to the care he provided to the 59-year-old male, identified only as Patient A, who had been admitted to the hospital’s intensive care unit after being diagnosed with bacterial meningitis. The committee was informed that Dr Sathivel accepted that his failure to have regard for the stated view of a clinical nurse manager, Rosanne Kenny, that Patient’s A endotracheal tube had become dislodged about 3.58am on February 24, 2019 constituted professional misconduct. Read full story Source: The Irish Independent, 29 May 2025- Posted
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News Article
Tenth review into maternity care at Portiuncula Hospital now underway
Patient Safety Learning posted a news article in News
According to the Irish times, it comes after a series of serious incidents, including seven cases of babies suffering brain injuries during or after birth since 2024. A tenth review into maternity care at Portiuncula Hospital in Ballinasloe is now underway following the recent death of a baby. According to the Irish times, the HSE investigation, comes after a series of serious incidents, including seven cases of babies suffering brain injuries during or after birth since 2024. Six of those infants required specialist cooling treatment. Two stillbirths in 2023 are also under external review. Read full story Source: Shannon Side, 16 May 2025 -
Content Article
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. -
News Article
Ireland tackled tainted blood scandal decades ago - and it has cost €800m so far
Patient Safety Learning posted a news article in News
Ireland’s blood scandals have caused human suffering and cost the State around €800m in compensation so far. A damning inquiry report in the UK this week found that authorities there covered up the infected blood scandal after knowingly exposing victims to unacceptable risks. More than 30,000 people in the UK were infected from 1970 to 1991 by contaminated blood products and transfusions. Ireland moved decades faster to address the contamination tragedy. The tribunal set up to compensate people infected by contaminated blood transfusions or blood products in the Republic of Ireland has paid out around €800m since 1996. In Ireland a compensation tribunal, which is still sitting and will continue to do so for years to come, was set up by the government in 1995 first to compensate women infected with hepatitis C as a result of the use of contaminated human immunoglobulin anti-D. This blood product was given to women with the rhesus-positive blood type to protect future pregnancies. The Finlay inquiry in the mid 1990s looked at the rules that were broken by the then blood transfusion service in producing anti-D. The Lindsay tribunal set up in 2000 examined the contamination of Factor 8 products used by men with haemophilia which were contaminated with HIV and hepatitis C. The tribunal heard how home-produced blood clotting agent caused infection in seven haemophiliacs despite earlier claims that it was safe. Read full story Source: Irish Independent, 21 May 2024- Posted
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Protecting patients (20 March 2004)
Patient-Safety-Learning posted an article in Whistle blowing
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.- Posted
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Irish medical regulator says regulating physician associates is outside its remit
Patient Safety Learning posted a news article in News
The Medical Council, the medical regulator for Ireland, has announced that it believes it is not the appropriate body to regulate physician associates (PAs)—in sharp contrast to the position in the UK where the General Medical Council takes on this role from 13 December. The role of PA was introduced in Ireland in 2016 by the Royal College of Surgeons in Ireland’s School of Medicine which offers the only masters in physician associate studies in the Republic of Ireland. To date, 76 PAs have graduated from the two year programme with 60% working in public hospitals and 40% employed by the private sector. The GMC estimates that there are around 5000 PAs and 200 anaesthetic associates (AAs) in the UK. PAs are not yet subject to statutory regulation in Ireland but there is a managed voluntary register, which lists all fully qualified PAs who successfully fit the criteria to practise as a PA in the Republic. The register is designed to provide public protection and safety and is managed by the Irish Society of Physician Associates. In a position statement2 published on 3 December, the Medical Council said it was not the appropriate regulatory body for PAs. “The Medical Practitioners Act 2007 has no provision to regulate health professionals other than doctors,” said the statement. “The Medical Council’s primary purpose is to protect the public by setting high standards of professional conduct, education, training, and competence among doctors.” The council also said there was potential for emerging patient safety risks arising from confusion for patients, as observed recently in the UK. Read full story Source: The BMJ, 12 December 2024 Further reading on the hub: Physician associates: What are the patient safety issues? An interview with Asif Qasim- Posted
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Content Article
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.- Posted
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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.- Posted
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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.- Posted
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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. -
Content Article
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.- Posted
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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.- Posted
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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- Posted
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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- Posted
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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.- Posted
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News Article
Irish medical negligence legal costs among highest in world, report says
Patient Safety Learning posted a news article in News
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- Posted
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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- Posted
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Event
untilThis Westminster conference will assess priorities and next steps for addressing the impact of Long Covid in Ireland. Areas for discussion include developing and implementing research into Long Covid, the state of specialised services in Ireland, and the implementation and development of the Model of Care, which recommended the development of eight post-acute and six Long Covid clinics. It will be a timely opportunity to discuss Ireland’s strategy for tackling long COVID following analysis from Denis Naughten TD - who is part-chairing this conference - which suggests that almost 340,000 people in Ireland could have been affected by long COVID. It also follows a motion forwarded by a regional group of TDs calling for swifter action to support those with long COVID, which secured unanimous Dáil Éireann support. With the HSE now implementing the Model of Care for long COVID, and developing an epidemiological survey to gauge long COVID numbers in Ireland, delegates will assess the development of the model, workforce and recruitment priorities, and next steps for research and data. It will include keynote sessions from Dr Siobhán Ní Bhriain, Consultant Psychiatrist & National Clinical Director, Integrated Care, HSE; and Professor John Lambert, Consultant in Infectious Diseases and Genitourinary Medicine, Mater Misericordiae University Hospital and Associate Professor, UCD School of Medicine. Overall, sessions in the agenda will look at: the interim model of care: priorities for development and for creating a centralised care hub to provide support. long COVID clinics: next steps for implementation - providing effective staffing and funding - tackling long COVID backlogs and waiting lists - relieving pressures on GP waiting lists. patients: assessing and providing the support needed by those with long COVID and identifying those most at risk - options for workplace support and assisting those out of work to return quickly. research: building on data from current long COVID and post-acute COVID clinics to inform future strategies - implementing effective surveillance to understand, scale and respond to the issues. policy coordination: integrating responses with Sláintecare reforms and waiting list strategies. Register- Posted
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untilThis webinar from the Irish Health Services Executive National Quality and Patient Safety Directorate will enable you to: understand what restorative just culture means in practice appreciate how you can apply restorative just culture to your local context learn the benefits of restorative just culture for patients, staff and business hear top tips for applying restorative just culture Register for the webinar- Posted
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untilBringing together a community of human factors in patient safety advocates across Ireland and abroad, the annual Human Factors in Patient Safety Conference will offer the opportunity to gain valuable knowledge and insights from human factors experts. The conference will include contributions from: Martin Bromiley OBE, Founder of Clinical Human Factors Group UK – Listening Down to Develop your Safety Behaviours Mr Peter Duffy, Consultant Urologist – Whistle in the Wind: a Personal Exploration of the Consequences of Whistleblowing in Healthcare Professor Eva Doherty (Chair), Director of Human Factors in Patient Safety – The Irish Context, panel discussion Healthcare professionals can register for the event here. For more information, please email [email protected].- Posted
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Content Article
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. -
Content Article
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.- Posted
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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.- Posted
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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)- Posted
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