Patient safety report: main recommendations

A summary of the Commission on Patient Safety's report recommendations

A summary of the Commission on Patient Safety's report recommendations

* Create a national network of patient advocates who will work in partnership with healthcare organisations.

* A public information service should be developed by Hiqa and the HSE which makes information readily available to patients and carers when dealing with illness.

* Implement national standards for open disclosure of adverse events to patients.

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* Strengthen existing senior professional roles such as that of chief medical officer within the Department of Health and create new patient safety leadership roles within Hiqa and the HSE.

* Professional regulatory codes of conduct (clinical and managerial) must make patient safety a priority as the primary duty of all health professionals.

* The chief executive within each defined healthcare organisation must be ultimately responsible and accountable for patient safety and quality within that organisation.

* Health service management teams should demonstrate competence-based training and be subject to ethical and disciplinary codes similar to other healthcare professionals.

* There should be mandatory licensing systems in the Republic to cover both public and private healthcare providers, including hospitals, primary and community care.

* The licensing function should be assigned to Hiqa and the impact of licensing on patient safety be formally reviewed after three years.

* Private health insurers should require all private healthcare facilities to adhere to the standards set by Hiqa.

* A new group representing all professional regulatory bodies will develop plans for a first point of contact for patient concerns over clinical care, with referral as necessary to appropriate regulatory bodies.

* Create a system of alert notices for the exchange of information between healthcare employers in respect of health professionals for whom patient safety issues have arisen.

* A national mandatory reporting system should be introduced for the collection of standardised information on adverse events that result in death or serious harm.

* Professional regulatory bodies should include mandatory reporting of adverse events as an ethical obligation within their codes of practice.

* Validated patient safety data should be made available to the public in annual reports.