MEDICAL NEGLIGENCE PATIENT SAFETY

Patient Safety Events in Ireland refer to incidents or occurrences during healthcare delivery that either result in harm to a patient or have the potential to cause harm.

Patient Safety Events are tracked through reporting systems like the National Incident Management System (NIMS), managed by the Health Service Executive (HSE) and other healthcare bodies such as the Health Information and Quality Authority (HIQA).

Types of Patient Safety Events

1. Adverse Events

a) Incidents where a patient suffers unintended harm as a result of medical care, rather than their underlying condition. These can include mistakes in treatment, diagnosis, surgery, or medication administration.

b) Examples include incorrect medication dosages, inappropriate surgery, or failure to act on test results.

2. Near-Miss Events

a) Events that could have caused harm to a patient but were prevented before any injury or harm occurred.

b) Near misses include situations like detecting a wrong medication before it is administered or catching an incorrect surgical procedure before it begins.

3. Serious Reportable Events (SREs)

a) Also known as "Never Events," these are significant, preventable patient safety incidents that should not occur if proper precautions are in place. These incidents often result in significant harm or death.

b) Examples of serious reportable events include surgery performed on the wrong body part, wrong-patient surgery, retained foreign objects after surgery, or medication mistakes that cause severe harm.

4. Healthcare-Associated Infections (HAIs)

a) Infections that patients acquire during the course of receiving healthcare treatment for other conditions.

b)  These events are often preventable through better hygiene practices, such as hand washing and the use of sterilised equipment.

5. Medication Errors

a) Events where a mistake occurs in prescribing, dispensing, or administering medication that leads to harm or has the potential to harm the patient.

b) They are often preventable through proper communication and adherence to protocols.

6. Falls

a) Patient falls, largely in hospitals and long-term care facilities, are a common safety event. Falls can cause serious harm, including fractures, head injuries, or even death, especially in elderly or vulnerable patients.

b) Fall prevention programmes are implemented to minimise risks, but these events still occur when patients are not adequately monitored or supported.

7. Pressure Ulcers (Bedsores)

a) Pressure ulcers occur when a patient’s skin is damaged due to prolonged pressure, especially among patients who are immobile for extended periods. These events are preventable through frequent repositioning and proper skin care.

b) The development of pressure ulcers is considered a preventable adverse event that reflects gaps in care or attention to patient needs.

8. Surgical Errors

9. Diagnostic Errorsa

a) Failures in diagnosing a condition correctly or delays in diagnosis that lead to harm for the patient. This includes missed diagnoses, misinterpretation of test results, or failure to follow up on abnormal findings.

b) Diagnostic mistakes can lead to inappropriate treatments, worsening of the patient's condition, or death in severe cases.

10. Blood Transfusion Reactions

a) Safety events related to the administration of blood or blood products, such as transfusing the wrong blood type or failure to monitor a patient for adverse reactions. These mistakes can lead to serious or life-threatening complications.

b) Strict verification procedures are in place, but mistakes sometimes occur due to communication failures or procedural mistakes.

11. Maternal and Neonatal Events

a) Events involving harm to mothers or newborns during pregnancy, childbirth, or the postpartum period. These may include failures in monitoring fetal distress, complications during delivery, or improper postnatal care.

12. Failure to Rescue

a) This refers to the failure to respond to signs of patient deterioration in time to prevent harm, such as missing or delaying treatment for conditions like sepsis, cardiac arrest, or respiratory failure.

b) Early detection and rapid response systems, like the National Early Warning Score (NEWS), are used to monitor patient vital signs and intervene early in such cases.

13. Communication Failures

Miscommunication between healthcare providers, or between providers and patients, that leads to a Patient Safety event. These events often occur during patient handovers, shift changes, or discharge from a hospital.

14. Patient Identification Mistakes

Events where a patient is misidentified, leading to wrong treatments, procedures, or medication. Common identification mistakes include confusion over patients with similar names or failure to follow proper verification procedures.

15. Patient Suicide or Self-Harm in Healthcare Settings

A tragic event where a patient, often in a psychiatric or general hospital setting, commits suicide or engages in self-harm while under care. Such incidents can show gaps in mental health monitoring or risk assessment.

For more detailed insights into how the Patient Safety Act 2023 impacts you and how Whelan Law can support you, please visit our Patient Safety Rights Legal Advice https://www.whelanlaw.ie/news/medical-negligence-and-patient-safety/