The health watchdog has called for medical negligence, errors and mistakes across the health and social care sectors to be reported to a single agency to improve patient safety.
The Health Information and Quality Authority (Hiqa) said a one stop shop was needed to allow staff to share and act on information about incidents and to learn lessons to prevent them from being repeated.
It is the second time it has been recommended to Health Minister Leo Varadkar and the agency said it about creating a “just culture”.
Dr Kevin O’Carroll, acting director of health information with Hiqa, said: “There is currently no single agency in Ireland with responsibility for the governance and coordination of patient safety intelligence and for sharing learning between the numerous agencies which collect patient safety intelligence.
“The diffusion of this information is a lost opportunity to provide early warnings of potential patient safety risks.”
The advice was one of 10 recommendations issued by Hiqa after concerns were raised about the safety of maternity services following a number of baby deaths, including those at Portlaoise Hospital.
The 2014 Chief Medical Officer’s report on perinatal deaths in that unit made a similar call for a National Patient Safety Surveillance System to be created.
Dr O’Carroll said: “The primary purpose of patient safety reporting systems is to learn from when things go wrong for patients and staff, and to try and prevent such incidents happening again.
“The most important function of a reporting system is to use the results of data analysis and investigation to share recommendations for addressing patient safety risks.
“These systems must encourage healthcare workers to actively report incidents through the establishment of a reporting environment which balances the need to learn from mistakes with accountability.”
Hiqa carried out a comprehensive review of patient safety intelligence systems in British Columbia in Canada and in Denmark, England and Scotland and how the Irish systems compares.
Its recommendations also included assigning responsibility and accountability for national patient safety intelligence to an independent organisation and developing effective IT systems to gather and record the intelligence on safety.
It said a national incident management system should be set up across the health and social care system with new laws brought in to support incident reporting. It also said improving data quality and the use of incident information were required.
Hiqa said a review of the experience in Ireland showed there is a need for better governance and coordination of national patient safety intelligence.
