NMH

NMH | 2024 168 Quality & Safety Services T he Quality, Risk and Patient Safety (QRPS) Department continues to strive to promote the highest standards of care throughout the hospital. 2024 saw several changes and developments. Dr Anne Twomey, Director, and Laurence Rousseill, Clinical Risk Manager, both retired. We wish them well and thank them for their diligence and dedication. Fidelma Martin, Patient Safety Officer was promoted to CMM3 post. Martin Creagh was appointed as Senior Risk Manager, with responsibility for non-clinical risk management. Kim Ryan continues as Patient Safety Advisor and Vanessa Goldwater as Administrator. Rachel Irwin remains as Quality Manager, assisted by the two Patient Advocates, Jenny McCrea and Roisin Moran. Rachel is now one of the two review officers in the hospital for Level 3 complaints. These were previously referred on to the former Ireland East Hospital Group. Both Jenny and Roisin have also taken on the role of Designated Person, mandated under the HSE Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023. This Act formally commenced on 26th September 2024. Dr Orla Sheil has been seconded to the Department as Director. The Department appreciates the administrative support provided by Patient Services to support Vanessa, particularly with the National Incident Management System (NIMS) reporting. Clinical Incident Management Significant development of the QRPS Clinical Incident Management System (CIMS) reporting mechanism on the Zoho platform took place during the year. The results are now becoming evident in terms of more efficient incident reporting and recording. 2025 will see the first full year of records on the new CIMS 3 console which hopefully will allow us to share our data clearly and graphically with both the regulatory agencies, HSE, HIQA, State Claims Agency, Obstetric Event Support Team (OEST) at NWIHP and also hospital staff. The need for onsite Zoho support has been recognised by the Executive Management Team (EMT) and a post has been advertised. Clinical incidents are categorised and reviewed both within the Department and also at different internal multidisciplinary review meetings, such as Clinical Incident Review Group (CIRG) and the NMH Women and Neonates Serious Incident Management Forum (SIMF), depending on their category. The most significant incidents, Serious Reportable Events (SREs) are also reviewed externally at the HSE Dublin and South East Women and Neonates SIMF. This forum is attended by the OEST. Actions and learnings from these incidents are shared within the Hospital and also with regional and national authorities. In 2024, 1,691 incidents were reported: 94 Category 1, 1,020 Category 2 and 577 Category 3. This number is similar to the previous year (1,634), though slightly different per category. The type of incidents in each category were reviewed resulting in some re-categorisation. Figure 1 shows the 2024 data compared with the previous two years. Learnings from these incidents and reviews have resulted in many quality improvement projects and staff education sessions as outlined here: Quality, Risk and Patient Safety Sharing the Learning through staff education, liaison and support: • Monthly 'Druggle' (in collaboration with Pharmacy colleagues) • BRAVO Award (supported by EMT) • After Action Review and Staff Debrief • Antenatal Anaemia Log (pilot in OPD) • Postnatal Discharge Summary Audit and QI Cards (in collaboration with our postnatal and community midwifery colleagues) • 'Safety Crosses' (planned for Unit 4 and NICU) • Monthly 'Learning from Incident Reporting' (across Hospital) • Patient Safety Alerts (across Hospital) • Q-Pulse Policies and new Pathways The Hospital is compliant with the HSE Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023. This requires mandatory reporting of, and open disclosure meetings for notifiable incidents as outlined in the legislation. The main requirements are summarised below. This process is coordinated and recorded by the QRPS department. It is a significant additional workload requiring resources which the EMT has supported. Requirements: • Notification of Notifiable Incidents to the relevant regulatory body (HIQA) within 7 days from when the health services 1200 1000 600 400 0 Figure 1: Incidents 2022-2024 200 800 2022 797 566 26 2023 854 716 64 2024 1020 577 94 Total Clinical Incidents Reported by Staff Year on Year Category 3 (Minor/Negligable) Category 2 (Moderate) Category 3 (Major/Extreme)

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