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Dublin International
Patient Safety Conference Croke Park
Jointly organised by the Irish Health Information and Quality Authority
(HIQA) and the WHO's World Alliance for Patient Safety (WAPS).
6th September 2007
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Over the proceeding three days, "patient champions" of the WHO Patient for Patient Safety
Alliance from most of the 52 countries of WHO Europe and also from the Eastern Mediterranean,
engaged in a series of workshops. They then joined the conference which was attended by
250 delegates in total from Ireland and across the world. AMNA delegate from Northern
reland represented the lEU-ALLIANCE. The Conference itself was a useful time for networking
amongst the delegates.
The tone of the Conference was set by two quotations:
"The greatest impediment to preventing harm is that we judge and punish people for their
mistakes." Prof. Lucian Leape.USA.
“To err is human, to cover-up is unforgivable, and to fail to learn is inexcusable."
Sir Liam Donaldson CMO UK.
Mary Harney, Irish Minister for Health, delivered a powerful address referring to past failings
and the need for change, learning from industry, licensing and accreditation, better cancer
services, empowering patients and building a consensus on patient safety culture of "no blame"
is the key to disclosure.
[lEU believes that there must be a Statutory obligation to disclose,
because patients are entitled to the truth if damage has occurred.]
Sir Liam Donaldson, CMO ( UK ) Chair of WHO and WAPS emphasised the need to engage with patients
in 'direct dialogue' and the importance of the patient.. He referred to the pathway of : safety
-duty - apology-explanation- learning' when something goes wrong.
"Every time I meet a patient or family who has suffered because of a healthcare mistake, I
know we are not working fast enough to make the far-reaching changes needed to improve patient
safety. We need to act quickly; we need to set clear measurable goals; and we need to be
accountable to patients everywhere for their delivery".
Five cases were outlined.
Dr Tracey Cooper [former NHS Clinical Director] Chief Executive Officer of HIQA highlighted
the core values at the heart of Patient Safety. The Health Care Service should ensure that when
things go wrong, it responds appropriately, actively and supportively.
[The lEU would like to see the following words more precisely defined:
'appropriately'- does this mean an obligation to report an Adverse Medical Incident (AMI)?
'actively' - does this mean informing the patient of the damage sustained? and
'supportively' - does mean support for health professionals and patients?]
When a patient suffers from an adverse healthcare accident they are openly communicated with,
staff are supported, action is taken and lessons learnt.
[The lEU wonders what exactly is meant by the term:
'openly communicated with" - does this mean a full honest and open disclosure irrespective of
legal liability? Also, the lEU has no objection to staff being supported, but the damaged
patient or the relatives in the case of a death must also receive support and counselling.
'action is taken' - does this mean full disclosure? - compensation offered
where appropriate?]
Key phrases:
“THE time for Patient Safety" "No international guidance on supporting .... damaged patients"
[This is very true and we are pleased that it has been admitted - in fact most damaged patients
are neglected and genuine health care is withdrawn because honest disclosure cannot take place
because of legal liability]
"protective disclosure"
[This is an interesting phrase and suggests what we have long suspected that the Healthcare
Institutions are still practising a defensive 'denial and cover-up culture and only release
part of the truth- this MUST change and health professionals must be able to be honest with
damaged patients and be free to offer genuine remedial care].
Dr Mary Hynes, Assistant National Director, Quality, Risk and Customer Care referred to the
recent safety events involving contaminated blood and asked for better record management.
Prof. Clifford Hughesgave accounts of 11 patients who received contaminated fluid.
Mr. John Bryan spoke on his experiences of near misses in medicines dispensing and the need
for change in preventing such incidents.
The Patient' Experience involved: Mary Vasseghi [cardiac death in the young], Sarah Yaron
[Israel -undiagnosed tumour in daughter- became a negligence lawyer- now focused on mediation],
and Vasyl Kvartink [Ukranian Council for Patients Rights) in interviews with Aine Lawlor,
radio 1 TV/journalist.
Professor Hughes, cardio-thoracic surgeon and CEO, Clinical Excellence Commission, New South
Wales, and a Foundation Member of the Australian Council for Safety and Quality in Health Care.
He spoke about progress in Australia, and particularly N.S.W.,on the bringing in of Open
Disclosure. Reference was made to Adverse Medical Incident notification, grading of events
determining levels of intervention and investigation. He drew attention to the slow progress
of national pilots on open disclosure. However progress was being made but changing attitudes take time.
[Damaged patients do not have time, and have waited
too long for the truth and genuine remedial care]
Professor Albert W.Wu of Bloomberg School of Health and Johns Hopkins Hospital University, USA.
He is the author of influential papers on medical errors, referred to trigger events fostering
change e.g. death of Sorrel King's daughter from dehydration and the introduction of open
disclosure in John Hopkins. He referred to the research of Professor Charles Vincent in the U.K.
and outlined barriers to disclosure eg the shame! fear! ignorance of the health professional
who inadvertently causes the medical error. The need for training on how to break bad news,
what to say to damaged patients.
Dr. Deidre Madden, law lecturer, author in medical ethics and recently appointed chair of the
new Commission on Patient Safety and Quality. She outlined key elements of the "quest for
perfection" in healthcare. Since it is an "imperfect science", errors will occur. What happens
after a mistake is the issue.[The lEU -Alliance is in agreement]. A Patient Safety Unit has been set up.
Ms Hilary Coates, Project leader for WHOIHIQA Project, formerly of WHO WAPS, and joint Chair
of the International Society for Quality in HealthCare's leadership and Education Working Groups,
outlined the project objectives-when things go wrong - developing guidelines and building commitment
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Margaret Murphy, whose son Kevin died from undiagnosed high blood calcium levels in 1999,
responded on behalf of the WHO Patients for Patient Safety European Group. She referred to
the empowering and healing aspects of an open disclosure process, with mutual respect and
understanding and engagement between patient, relative and clinician.
Dr. Cooper, CEO HIQA, brought the event to a close with a Q and A Session.
The lEU is delighted by progress that has been made over the last few years during which opinions
of health professionals and iatrogenic patients and their families have been sought.
Recognising that adverse incidents are inevitable is a major step forward. Whilst it is essential
that recording of medical errors and their analysis should progress rapidly, the lEU would urge
that more attention is paid to the other half of the equation - how to treat the innocent
victims of a medical error.
The WHO World Alliance for Patient Safety (WAPS) in collaboration with the health Information
and Quality Authority of Ireland (HIQA).
In May 2002 the 55 the World Health Authority ( WHA) adopted WHA Resolution 55,18.This urged
countries to pay the closest attention to the problem of Patient Safety.
In May 2004 the 57th WHA supported the creation of the World Health Alliance for Patient Safety (WAPS).
This was been a major force for the improvement of Patient Safety Internationally.
- Identifying best current practice for communicating & supporting patients and clinicians
after an adverse incident (AMI)
- To determine the outcomes desired by patients, families and clinicians in the aftermath of an AMI. To develop an International Consensus Guidance to identify best practice for communicating
with patients and clinicians in the aftermath of an AMI in order to facilitate a more responsive ,
positive outcomes for all parties.
The IEU-Alliance believes that their IEU Declaration July 2005 is a major initiative for the
promotion of Patient safety in Europe and represents the Patients’ Voice in Europe.
The IEU is indebted to AMNA for this report.
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IEU-Alliance in the WHO Patient For Patient Safety Newsletter
6th November 2006
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“An exciting venture has been the “European Initiative” when SIN-UK was invited to join several
like-minded European Patient Support Groups, for the problems faced by the damaged patient are similar
throughout Europe. The Iatrogenic Europe Unite ( IEU) Alliance was formed, the July 2005 Declaration
was produced incorporating the ‘Aims & Objectives’ of SIN-UK. This was presented to the members of
the Council and Parliament of Europe in March 2006. The IEU-Alliance was well received and seen as a
further step towards a patient friendly Europe. A Teleconference with the WHO PFPS in September 2006
was a welcome and productive experience.”
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