Ireland's interim Health Information and Quality Authority (iHIQA) and the World Health Organization launch a collaborative project on Patient Safety
The interim Health Information and Quality Authority in Ireland is an independent body that drives and advocates for quality and safety across the health and social services in Ireland on behalf of the citizen. The Authority is fully committed and focused in its role to drive improvements in the safety of patients and other users of the service and has therefore developed a strong partnership with the World Health Organization - World Alliance for Patient Safety to undertake a collaborative project in order to learn from and inform national and international patient safety developments.
There is growing recognition that, although many patients receive good quality care, a percentage of patient experience errors during their care and treatment. Globally there has been very little attention paid to supporting patients after such events. The limited research into this topic shows that patients and their families endorse disclosure and want information about what went wrong, why the error occurred and what are the long-term consequences but most importantly want an apology. In survey of internal medicine patients in an academic setting Witman found that 98% of patients desired acknowledgement of even minor mistakes. Patients and families report that very often, when things go wrong, they are met with a wall of silence with little information forthcoming. Patients also report that learning opportunities are often frustrated by damage limitation efforts following an adverse event.
There is also little research done on the impact of error on healthcare providers but it has been shown that clinicians frequently report a degree of emotional impact so that some mistakes were remembered for years. Clinicians also report feelings of guilt and isolation and the lack of learning and support systems available together with the fear of retribution and litigation.
This culture of defensiveness and blame fuels confrontation and damages the relationship of trust between healthcare provider and patient and often drives litigation rather than offering healing to all parties. The Authority recognises that there is a need to prepare the environment and transform the culture from blame to learning and continuous improvement if the citizens of Ireland are to have the safe and quality health service they deserve.
For more information please contact Hilary Coates at the Health Information and Quality Authority, Ireland.