Putting patient safety first

In the midst of an extraordinary level of activity within the Department of Health lately around the area of patient safety, …

In the midst of an extraordinary level of activity within the Department of Health lately around the area of patient safety, three pieces of genuinely frightening information have emerged, writes Mary Raftery

The first comes from the Minister for Health herself, and received remarkably little attention. In announcing the creation of her new Commission on Patient Safety and Quality Assurance last month, she made a ground-breaking admission.

She acknowledged that every year 100,000 Irish people suffer an injury directly as a result of the medical treatment they receive. In the jargon used, these are called adverse events. One thousand people every year die as a result of them, according to Mary Harney. That's almost 20 deaths a week caused by medical mistakes.

The Minister did not put it exactly as I have above. She was considerably more opaque, which may explain the relative lack of interest in her statement. She pointed to research carried out elsewhere which indicates that 10 per cent of hospital patients suffer an adverse medical event, and that 1 per cent of this group will die as a result. She said that Ireland was likely to be no different from elsewhere in this regard.

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When you do the sums, based on Department of Health figures of roughly one million cases treated by Irish hospitals annually, you get a much more immediate sense of the scale of the problem. Families traumatised by the unnecessary loss of their loved ones, people already ill having to cope with increased pain and suffering - throughout the country, almost 2,000 people a week damaged by the treatment they receive.

Amid all the rows over waiting lists and A&E queues, there has been one mantra, repeated endlessly. It is that once you get into the system, the treatment you receive is outstanding. This assumption clearly needs to be revisited in the light of the Minister's admission. If 100,000 people a year become victims of their treatment, then clearly their quality of care is anything but excellent.

Further alarming information which emerged last month relates to the truly staggering levels of error in drug prescriptions for hospital patients. In one major Dublin teaching hospital, St Vincent's, a study found that over 60 per cent of patients admitted through its emergency department had mistakes in the prescriptions they were given for medication.

Drug errors can vary from the relatively minor to the lethal. That almost two out of every three patients admitted through A&E could be prescribed either too much or too little medication, or even the wrong drugs entirely, is seriously disturbing. And there is no reason whatsoever to believe that St Vincent's differs significantly in this respect from any other hospital in the country.

A further study in Cork confirms the appalling vista. It examined a group of 600 elderly patients admitted to Cork University Hospital over a four-month period last year, and showed that 52 per cent of them were given the wrong medication. In some cases, this "inappropriate" medication led to patients having to be further hospitalised.

These kinds of studies are enormously valuable in breaking down the culture of denial which continues to pervade the medical profession on the issue of the mistakes they make. What is heard most often from them is that there are no figures for errors in Irish hospitals, and that it is invalid to extrapolate from findings within other health systems.

For decades, the Department of Health has done nothing about this. While former minister for health Micheál Martin did acknowledge in 2001 that we had a significant problem of medical error, he made no effort to deal with it.

Mary Harney, conscious no doubt that some day the shocking number of deaths and injuries caused by treatment might actually become an election issue, has at last taken action, albeit of a limited nature. While she does deserve some credit, the effectiveness of the blitz of bodies, authorities and commissions she is establishing remains highly questionable.

We will have the Health Information and Quality Authority, but that seems to be more about nursing homes inspections (itself much needed) than about how to tackle medical error.

The new Medical Practitioners' Act, with its insistence on continuing education for doctors, will certainly be useful, although it also does not directly address the issue of error, how to record and reduce it.

Then we have the Commission on Patient Safety and Quality Assurance. This is a talking shop, whose function seems to be to report to the Minister in 18 months' time on measures to tackle medical mistakes.

Never mind that we have had any number of reports and recommendations on patient safety in the past.

It is akin to deciding to call a meeting of the passengers in your car when faced with imminent head-on collision. In the 18 months it will take this commission to report, 150,000 people will have been injured by their treatment in hospital and 1,500 of them will have died as a result. That alone should make this an issue on which a government should be judged at election time.