Measuring and monitoring patient safety in hospitals in the Republic of Ireland

A commitment to safe healthcare is a policy goal of governments across the world. However, progress on delivering on this aspiration has been modest, with patients still suffering avoidable harm [1] and rates of harm remaining unchanged over time [2]. The impact that valid and reliable safety data can have on improvement is clear from many domains of healthcare [3]. Although safety data is complex and multi-faceted, it is vitally important to reducing patient harm [4]. This data is required to support the meaningful comparisons between the safety performance of different healthcare organisations and the assessment of the impact of safety interventions [1].

A recent review found that there has been relatively little research carried out on measuring and monitoring safety (MMS) in the healthcare system of the Republic of Ireland [5]. However, there is a recognition that MMS is central to patient safety improvement. This is evident in the Irish Health Service Executive (HSE) patient safety strategy which includes a commitment to ‘using information to improve safety’ (p.8) [6]. Recognising the complexity and multifaceted nature of the MMS in healthcare, Vincent et al. developed the MMS framework [4, 7]. The dimensions of the MMS framework are as follows:

The framework has been used previously to categorise studies in systematic or scoping reviews of MMS in primary care [8], prehospital care [9], and secondary care in Ireland [5] and Saudi Arabia [10]. The study reported in this paper uses Vincent et al.’s [4, 7] MMS framework to classify the methods of MMS used within secondary care in Ireland. The aims of the study reported in this paper are to (1) examine how patient safety is measured and monitored in Irish hospitals; (2) map the methods of MMS in these hospitals onto the five dimensions of Vincent et al.’s [4, 7] MMS framework; and (3) reflect on the approaches used to MMS in Irish hospitals.

A fundamental challenge to improving patient safety in healthcare is a dearth of high-quality information that allows organisations and individual practitioners to analyse their performance, define priorities, and identify areas of deficiency and risk. In this study, we examined how patient safety is measured and monitored in Irish hospitals, mapped these methods onto Vincent et al.’s [4, 7] MMS framework, and reflected on the meaning of these findings for MMS in Irish hospitals.

Considering both the findings from the document analysis and interviews, it can be seen that a wide variety of methods are used to MMS in Irish hospitals. However, although there were measures from across all five of the MMS framework dimensions, there was some variability in the number of methods within the dimensions. Measures of the reliability of safety critical processes were the most commonly identified methods of MMS in the document analysis and interviews. This may reflect the amount of routine safety data that are collected in Irish hospitals. The dimension with the smallest number of measures was sensitivity to operations. A possible explanation for this finding is that these measures tend to be qualitative (e.g. talking with patients and staff, observing staff) [16]. Such ‘soft intelligence’ is generally more difficult to collect, and analyse, than is the case for quantitative data [17]. However, this qualitative data can provide valuable insights into issues that may not be possible to gain from quantitative methods of MMS. Automated language analysis methods are beginning to be used to analyse qualitative patient safety data [18]. Therefore, there is the potential for the analysis of qualitative data to become much easier, and faster, than in the past.

Of all the measures identified by the interviewees across the five MMS safety dimensions, incident reports were the most common method of MMS—identified by almost four-fifths of the interviewees. However, the international literature suggests that healthcare organisations may overly rely on the analysis of past events and past harms as a source of safety performance information [19‐21]. Thus, whilst it is positive that frontline healthcare workers are aware of the importance of collecting information on adverse events, it is important that the limitations of this particular measure are recognised. It is well known that reporting systems underestimate the prevalence of patient safety incidents [22] and overestimate the severity of harm [23]. Therefore, it is important to avoid an over-reliance on incident reports and past harm more generally, as the primary source of safety data.

The second most common method of MMS identified by the interviewees was clinical audit—identified by three quarters of the interviewees. Clinical audits are widely used in many healthcare systems to assess clinical performance against pre-set standards and use the data to improve practise [24]. Nevertheless, despite their widespread use, audits’ effectiveness as a practise-improvement strategy is often presumed, rather than supported by robust evidence [24]. A review of the impact of clinical audit on healthcare workers practise and patient outcomes concluded that audits resulted in a little change, only 4% of the studies which used clinical audit resulted in an increase in the desired practise [25]. Research found that audits were more likely to be successful when there was low baseline performance, feedback was offered several times by a colleague or supervisor in both verbal and written formats, and defined objectives and an action plan were included [24]. Moreover, clinical audit places a considerable burden on staff to complete [26]. It is certainly not suggested that the health service abandons the practise of clinical audit. However, there is a need to consider how to reduce the resources, and burden, of MMS [3].

There are a wide range of methods of MMS in Irish hospitals. However, having larger numbers of methods of MMS does not necessarily correspond to a robust safety surveillance system. It is suggested that the input of all stakeholders in healthcare are gathered to identify particularly key measures, across the five MMS domains, in order to identify those methods of MMS that are particularly useful in reducing harm, supporting action and improvement, and do not place a large burden on healthcare staff to use or interpret.