AReviewofSeriousIncidentInvestigationReportsfromtheyears20092012:

Identifyingpatientsafetyissuesthatemergefromanoverviewanalysisof
nationaldata.

Author:LMullen
Date:20thJune2013

Background
ThereisconcertedefforttodevelopQualityandPatientSafetystructuresand
initiativeswithintheHSE.TheneedtodemonstratethattheHSEis
respondinganddoingwhatneedstobedonearisingfromitsseriousincident
investigationshasbecomemoreacute.Thisincludeslearningfromboth
internationalevidenceandthecompletedinvestigationsofseriousincidents.

ItisthepolicyoftheHSEthatthecommissionersofinvestigationsare
responsibleforensuringtheimplementationoflocallyapplicable
recommendations.Wherenationallyapplicablerecommendationsare
identifiedininvestigationsthecommissionermustarrangeforthesetobe
communicatedtotherelevantNationalDirectorfornationalimplementation
(HSE2009,andHSE2012).

Thisreportsummarisesfindingsfromaretrospectivequalitativesampling
andanalysisofregionalandnationalincidentreportscompletedbetween
20092012.Itisintendedtoprovideanadditionalanalysisofthehealth
serviceswhichhavebeensubjecttoseriousincidentreportsandidentifycare
deliveryproblemsandtheircontributoryfactorswhichfrequentlyreoccuras
patternsorthemesintheseriousincidentreportsandaremodifiablethrough
initiativestakenonanationalbasis.

QualityandPatientSafetydevelopmentsintheHSEareongoingandare
basedoninternationalevidenceonpatientsafety.Manyelementsof
healthcarethatharmpatientsareknownandmodifiablewithrobustpatient
safetyawarenessandsystems.InitiativesarecurrentlyinplaceintheHSEon
alocalandnationallevel.Areviewofcompletedinvestigationreportswas
undertakenwithanaimtoidentifynationallyapplicabletrendsandlearning.
Relevantliteratureanddatabasesystemswerealsoreviewed.
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Methodology
ArequestwasmadebytheNationalDirectorofQualityandPatientSafetyfor
thisqualitativereviewtobeundertaken.Inordertoobtainacomprehensive
reviewofcompletedseriousincidentanddeathinvestigationreportsbetween
theyears20092012aletterofrequestwasdraftedandsent.Theletterwas
senttotheRegionalDirectorsofOperations,AreaManagersforQualityand
PatientSafetyandtheNationalAmbulanceServicefromtheNationalDirector
ofQualityandPatientSafety.Theletterrequestedanelectroniccopyofall
completedseriousincidentanddeathinvestigationreportsbetweentheyears
20092012.Thecopiesweretobesentsecurelythroughinternalemailand
passwordprotected.Eachreportwasprinted,madeavailabletothe
researcherandstoredsecurely.Theelectroniccopiesarealsoheldinasecure
centrallocation.Theresearcherseparatedthereportsbyregionandtooka
samplefromeachregionforindepthreviewandanalysis,(table1.).

Table1.NumberofReportsReviewedbyRegionoftheHSE

Reviewedreports

Totalnumberof

Percentageof

reports

reportsreviewed

DML

17

32

53%

DNE

18

41

44%

South

21

28

75%

West

21

43

49%

Totals

77

144

53%

Reportswerereadcarefullyforcontent,themesandissuesemerging.A
templatewascreatedfortheextractionofdata.Aqualitativeanalysis
identifiedthemesemergingfromthereports.Theemphasisintheanalysisis
oncontributoryfactorsandissuesthatcanbeaddressedatanationallevel.


Reportscompletedbynationalagenciesandreportscompletedbythe
NationalIncidentManagementTeam(NIMT)inthetimeperiodwerealso
reviewed.Alistofthesereportsiscontainedinappendix1.

Results
Theresultsarepresentedintwoparts.Inthefirstsectionatableisgiven
whichprovidesexamplesofthetypeofcaredeliveryproblemsidentifiedin
thereportsandsomeofthecontributoryfactorsassociatedwiththese
problems.Thisisnotafullycomprehensivetableofeverycaredelivery
problemoreverystatedcontributoryfactor.Thetableillustratesthemost
commonproblemsidentifiedandgivesofflavouroftheessenceofthe
reviewedreports(Table2).Thesecondsectionoftheresultscontainsthe
thematicfindingsoftheanalysisanddiscussionofsomekeyissuesthatarose
fromthereviewofthereports.

Itisimportanttostatethatmanyreportscontainedasystemsanalysis
approachwhichincludedacareandmanagementreview.Thesecareand
managementreviewsoftenfoundthatthecareandmanagementofthe
patientwasinkeepingwithexpectedpracticesandstandards.Inanumberof
reportsreviewednocaredeliveryproblemswereidentified.

Table2.ExamplesofCareDeliveryProblemsandContributoryFactors
foundintheReviewofCompletedSeriousIncidentsandDeathReports
CareDeliveryProblems
Misseddiagnosisandfailureto
managefullinjuries

Failuretorecogniseandmanage
severityofconditionwithin
acceptabletimeframe

Delayedrecognitionofanacute
deterioration

HealthcareAquiredInfectionin
patients(HAI),

ManagementofHAIs

Delayintheearlyrecognitionand
treatmentofsepsis

Failuretodiagnosethecauseof
presentingsymptoms

ContributoryFactors
Failuretoconductrequested
diagnostictests

Deterioratingconditionundetected

Failuretoorderappropriatetests

PEWSdidnotidentify
deterioratingcondition

Failuretodocumentclinical
assessmentbyotherspecialist
consultation

Hygienestandards

Singlesourcedocumentation

BusyED,Languagebarrier,

communicationbetweenspecialist
teams,NCHDsnotresponding,

documentationnotrecorded/timed,
uncleartreatmentplan

Difficultiesrecognisingpatients
deterioratingcondition,delayin
response

Urgentreportswerenotwritten
intochartbutcommunicated
verbally

Multimorbidityinpatient

Patientmanagementsystems

Delayedmedicalexamination/tests

Nodocumentation,lackof
definitiveworkingdiagnosis,no
writtencareplan

NoeffectiveMultiDisciplinary
Team(MDT)review

Consentprocesswasnot
Inadequatedocumentation/
documented
continuityofcare

Nostandardisationofpreoperative Nonadherencetopolicyand
marking
procedure

Failuretocarryoutmandatory
Delayinreportingincidentto
surgicalsafetychecklist
management

Delayintheinvestigationand
failuretoarrangeafollowuponce
managementofclinically
diagnosiswasmade
significantsignsandsymptoms,

KeyThematicIssues
Therewerefivekeythematicissuesthatarosefromthereviewthesewere;
documentation,therapidlydeterioratingpatient,patientandfamily
communication,notobservingstandardprotocolsandproceduresand
completedsuicide.

Documentation
Thereportscontaincommentandcriticismofthequalityandprecisionof
documentation.Thisincludesretrospectivecharting,chartswhichdonot
containinformationontimeandpersonmakingnote,timeperiodsinwhich
littledocumentationoccursonnotesordocumentationofasuperficialand
unsatisfactoryquality.Thesefindingsaremadeinanumberofunrelated
incidentreports,indifferentcaresettingsandacrossregions.Thelackof

accuratedescriptivedocumentationisacommonproblemasisthefailureto
complywiththerecordmanagementpolicyoftheservice.Overallmany
reportscommentthatthequalityofpatientrecordsispoor.Other
contributoryfactorstopoorpatientsafetyinvolvingdocumentationare;non
adherencetostandardpracticeandpolicies,skillmixofstaffcontributingto
documentationandfollowupsystems,turnoverandchangeoversofstaffand
servicesathighpatientcapacity.

RapidlydeterioratingPatient
Theincidentinvestigationreportscontainevidencethatfailuretorecognise
rapidlydeterioratingpatientsisleadingtodeathandseriousharm.Itis
identifiedbytheinvestigatorsasacaredeliveryprobleminasubstantial
numberofinvestigations.Combinedwithfailuretorecognisesymptomsand
subsequentfailuretosendfortestsandinadequatemonitoringitisthemost
commoncauseinthisdatasetofseriousdeathandharm.Thiscategoryisa
commonpatientsafetyissueinternationally.Thisreviewofreportsis
occurringatatimeanumberofinitiativessuchasearlywarningsystemsand
guidelinesarebeingimplemented.Itwilltaketimefortheseinitiativestobe
fullyimplementedandvigilancewillneedtobecontinuedafter
implementationinordertoinsurethatpoliciesandproceduresarealways
adheredto.Inanumberofcasesreviewedstandardisedpoliciesand
procedureswereinplacebutwerenotfollowed.Otherissuesare
communicationbetweenspecialtiesandthecultureandpracticeofMDT
reviewincludingtheorderingoftestsbydifferentspecialities,followupof
testsanddiscrepancymeetings.Communicationofunexpectedclinically
significant,orurgentfindingsbetweenteamscanbeanissueascanreport
turnaroundtime,andcompleteness.

Patientandfamilycommunication
Thereportscontainevidencethroughpatientinterviewsandpatients
complaintsthatpatientsandfamiliesoftendrewattentiontothepatientbeing
inadeterioratingstate.Therewasanumberofreportsthatcontainedformal
complaintsbypatientsandfamilies.Therewasasenseofnotbeinglistenedto
orbeingkeptinthedarkaboutissuesinrelationtopatientscare.Therewerea
numberofreportsinwhichconsentissuesaroseandpoliciesandprocedures
werenotadheredtobytheservice.Thereisaneedtoensureapolicyfor
managementofpatientsrepresentingtotheEDwiththesamecomplaint
withinadefinedtimeframe.Asmorecohesivemedicalrecordssystemsare
developedandthereisamovetoelectronicpatientrecords,onerecordwill
containalltheinformationavailableforeveryconsultationwhichwill
facilitatebetterpatientmanagementsystems.

Notobservingstandardprotocolsandprocedures
Inanumberofthesampledreportstherewasevidencethatguidelinesand
protocolswereinplacebutwerenotfollowed.Thisincludesthefailureto
orderappropriatetestsandprovidefollowupconsultations.Thisresultedin
misseddiagnosisandfailuretomanagefullinjuriesofpatients.Inmanycases
thedeterioratingconditionofthepatientwentundetected.Inanumberof
reportsitisclearthatteamreviewsdidnottakeplace,andtherewere
problemsofcommunicationbreakdownathandovers,andbetweenspecialty
teams.Therewassomehighlightinginthereportsofovercrowding/reduced
staffingandmorejuniormedicalstaffbeingpresent.

Suicide
Therewerealargenumberofinvestigationreviewsofcompletedsuicidesof
patientsinbothinpatient,acuteandoutpatientcare.Anumberofpatients
hadbeeninthecareofmentalhealthservicesforanumberofyears.There
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werebothpatientandsituationalfactorsthatwereidentified.Insomecases
nocaredeliveryproblemswereidentified.Alargenumberofthesuicides
wereinpatientswhocurrentlyorinthepastattendedmentalhealthservices
intheHSE.Mentalillnessisaknownriskfactorforsuicideanditcurrentbest
practicetoassessandmonitorforsuicidalideation.Thereareanumberof
guidelinesandprotocolsinplaceinthevarioussettingstoriskmanage
suicideanditisknownthatpatientsmostrecentlydischargedfromacutecare
areidentifiedasbeingamongthehighestriskofsuicide.Thisisavery
difficultphenomenathatwouldbenefitfromanindepthspecialistreviewof
cases.Asmallgroupofmentalhealthprofessionalsshouldconductareview
andidentifyinternationalbestpracticeinthisareaandhowtheHSEmight
preventandreducethenumberofcasesofcompletedsuicide.

Impressionofinvestigations.
Thispieceofworkdoesnotcontainaformalassessmentofthequalityand
completenessofinvestigationsandinvestigationreports.Neverthelessa
numberofgeneralcommentscanbemadeaboutthereportsasreviewedfor
thisreport.Thereportsarevariableintermsofwhetherornottheyareinthe
standardHSEformat.Thisimprovesinthelatterreportsfromthetime
period.Itisworthmonitoringtheuseofstandardisedinvestigationmethods
andreportformatsasitresultsinamuchclearerandmorecomprehensive
pictureandismucheasiertodrawconclusionsfrom.Reportsbenefitfromthe
summarysectioncontainedwithinthestandardisedreport.Thiscouldalsobe
furtherreducedtoaonepagecoversheetwithessentialdataandsummary.A
summarysheetwouldalsoaidcategorisationofreportsbyregion,typeof
incident,patientfactors,caredeliveryproblemsandcontributoryfactors.Itis
recommendedthatwhenasystemofannualreviewofreportsisinplacethat
regularauditofreportsshouldbedone.Thiscouldbeonthebasisof

reviewingallreportsorjustthosethatareclassifiedunderanincident
classification,locationorserviceofinterest.

Thereportsobtainedcanformthebasisofarepository.Therewillneedtobe
someclassificationofreports.Thisrepositorycanberegularlyreviewedand
interrogatedfordifferentpurposessuchasreviewofaparticularpatient
safetyissueorresearchwithappropriateprotections.Itwouldalsoaidan
annualreviewandreportoncases.Allreportsshouldbestampedormarked
confidentialinanelectronicform.Thisisnotthecaseatpresent.

Summary
Manyoftheissuesidentifiedinthisreviewareconsistentwiththefindingsof
nationalindependentinvestigationsandinquiryandinternationalfindings.A
numberofinitiativeshavebeendevelopedandimplementedintheyears
sincethesereportswerewrittenandtheincidentstookplace.Theseinitiatives
suchastheearlywarningscoringsystem(2011),publishingoftheHSE
standardsandrecommendedpracticesforhealthcarerecordmanagement
(V3.0,2011)andtheNationalConsentPolicy(2013)taketimetobe
implementedandembeddedwithinthehealthsystem.Theywillsupport
betterpatientsafetypracticesandcultureinthefuture.Thisreporthasfound
anumberofissuesthatwouldbenefitfromfurtherpatientsafetyinitiatives
anddevelopment,thecultureofsituationalawarenessandrobustsystems
andmanagement.Thisexercisewillbeperformedprospectivelyinthefuture
asbettersystemsandstructuresareinplaceforinvestigationreview.Thiswill
facilitatethetimelinessofreviewandimprovesafetyforallpatients.

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Appendix1DocumentList
HSEIncidentreportingguidance
Toolkitofdocumentationtosupportthehealthservicesexecutiveincidentmanagement.HSE,
March2009

Incidentmanagementpolicyandprocedures.HSE,2008

Seriousincidentmanagementpolicyandprocedures.HSE,2008

Guidelinesforsystemsanalysisinvestigationofincidentsandcomplaints.HSE,November
2012.

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Reportoftheinvestigationintothequalityandsafetyofservicesandsupporting
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Reportoftheinvestigationintothequalityandsafetyofservicesandsupporting
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ReportoftheinquiryintothecircumstancesthatledtothefailedtransportationofMeadhbh
McGivernfortransplantsurgeryandtheexistinginteragencyarrangementsinplacefor
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MentalHealthCommission
ReportofthecommitteeofinquirytoreviewcareandtreatmentpracticesinSt.Michaels
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ConfidentialmaternaldeathenquiryinIreland.ReportfortheTriennium20092011.MDE
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HSE(NationalIncidentManagementteam)
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