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The Department of Health has welcomed the publication of the report on Serious Reportable Incidents by the HSE which is a vital tool in improving patient safety levels throughout the health service.
The Department of Health’s Chief Medical Officer, Dr Tony Holohan, said: “The report contains the type of analysis that will add to our patient safety information and intelligence. It will assist us to identify patterns and trends in the occurrence of healthcare incidents”.
The report shows that the rate of SRE reporting is improving overall, but it identifies gaps and variations in the level of reporting. Until there is greater confidence about the levels of reporting, those units reporting higher numbers of SREs should not be interpreted as having higher rates of SREs.

Not all SREs are preventable and some may be unavoidable. However, new provisions to be included in the Health Information and Patient Safety Bill will make it mandatory to report all SREs.

At the same time, the National Incident Management System is now in place throughout the health service and is likely to reduce these gaps and increase the level of SRE reporting across the country.

The report provides detailed analysis of incidents which will allow worrying or negative patterns and trends to be identified, tackled, and improved. This sort of information is vital in order to build a robust patient safety culture in the health services. Mistakes will happen and we shouldn’t forget that behind these statistics are real people.
The Director of Patient Safety and Clinical Effectiveness, Dr Kathleen Mac Lellan, said “A strong patient safety culture encourages and supports incident reporting. By openly reporting incidents valuable learning is provided to the whole system and therefore steps can be taken towards reducing avoidable adverse events in so far as is possible.”
The Report follows on from the recent announcement of a comprehensive Patient Safety Package including plans to simplify the complaints procedure, enhance the powers of the Ombudsman and HIQA, a tranche of patient safety legislation, new measures to reduce the time taken for a legal action to be resolved and to reform methods of compensation payments.

It complements the first annual report of the National Healthcare Quality Reporting System (NHQRS), which was published earlier this year. The NHQRS allows us to compare the quality of healthcare across our country and at international level. Separately, the State Claims Agency published a five-year analysis of adverse incidents in gynaecological and maternity units last month.

Further detail on the report
This is a HSE report. It provides analysis for the first time in relation to SREs reported between March 2014 and September 2015 (19 months). SREs are a subset of patient safety incidents which adds to the overall picture of patient safety in Ireland. SREs are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers. Some SREs may not be preventable but require examination to assess if safety can be improved.