ANALYSIS:The commission has delivered a good report but funding to deliver on recommendations is key, writes Dr Muiris Houston
"[MEDICINE] IS an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line."
Dr Deirdre Madden, chairwoman of the Commission on Patient Safety and Quality Assurance, chose this quote from Atul Gawande, the US doctor and journalist, to begin her foreword to the commission's much anticipated report on patient safety.
Healthcare professionals emerge from training with a strong sense that errors are unacceptable: but, of course, mistakes will be made, because doctors and nurses are only human, and the structures they work in, which are often the root cause of error, have been designed by fallible human minds.
We need to see a major cultural change throughout the health system - one that freely acknowledges medical error, openly communicates mistakes to patients and their families and is committed to analysing and learning from mistakes in a blame-free way.
Building a Culture of Patient Safety sets out a framework that places patient safety at the top of the healthcare agenda. Reassuringly, it has examined the issue from the perspective of a person undertaking a journey through the health system. As a result, its recommendations go well beyond the hospital sector and address healthcare error in primary, continuing and community care.
With mistakes in the area of breast-cancer care fresh in the public psyche, perhaps the most important element in the report is the recommendation that private hospitals be subjected to the same mandatory licensing systems as public facilities.
This system failure meant that the Health Information and Equality Authority was unable to inquire into questionable practices at Barringtons' private hospital even though it instigated an investigation into public facilities involved in the care of the same patient.
Asking private health insurers such as the VHI to reimburse only those private hospitals which adhere to the authoity's standards is hugely important also.
The introduction of a formal licensing system for all health services - public and private, hospital, general practice and community care - will do much to protect patients from potential "cowboy" operators. There is an acute need for licensing, especially in the cosmetic surgery sector, which has seen some highly questionable practices and procedures, bringing regrettable consequences for patients.
By adopting a licensing system, Minister for Health Mary Harney must ensure the licensing agency is given the power to close a hospital or an individual unit within a healthcare institution. The public requires reassurance that institutions can be shut down rapidly if necessary.
Another key recommendation is the creation of a system whereby healthcare employers can issue alert notices, nationally and internationally, informing each other when patient safety issues linked to a particular doctor or nurse are identified. The employment of locums, especially at short notice, is a particularly risky area and one that was a key factor in recent breast-care scandals.
The report's recognition that many errors arise because of the actions of teams of healthcare professionals rather than individual practitioners is most welcome.
As multidisciplinary work becomes a central element of patient care, mistakes are more likely to involve clinical teams.
So the decision to recommend a new regulatory body to become the first point of contact for patient complaints, with onward referral to bodies such as the Medical Council and An Bord Altranais, should ensure a greater focus on system and team issues when patients are harmed.
Creating a formal network of people to act as advocates on behalf of patients is another important step forward. Badly needed in the area of mental health, advocates can work in partnership with healthcare organisations to ensure patients' interests receive the priority they deserve.
And the recommendation that health service managers will be obliged to demonstrate competence and be subject to ethical and disciplinary codes should help eradicate buck-passing and the demonising of individual practitioners when patients experience adverse events.
Dr Madden and her fellow commission members are to be congratulated on a job well done. However, a key question remains: will the Government ensure the necessary funding is put in place so that the report's recommendations become a reality?