Dr. Kathleen MacLellan:

Reference was made to our system of reporting adverse events and using that as a source of intelligence for us on what is happening in our system. We recognise that how we utilise that information has not been as optimum as it could be. As Dr. Holohan has said, there are a number of health care acquired conditions, if we were to call them adverse events. Internationally, it is estimated that 10% of patients will acquire something they did not have before they came in to the system. As part of the capacity building within the Department of Health, and from a policy point of view, we would like to see the creation of capacity to start looking at the surveillance of patient safety across the system. We have a lot of systems and we would see our National Incident Management System, NIMS, as a very important source of information; the types of incidents that happen, where and how they happen and how they are managed, along with other sources of information such as our hospital patient safety statements and maternity patient safety statements. We would like to take that information to guide where we go forward. A lot of what we are building now is built in the absence of a co-ordinated, planned for analysis of the information that we have around patient safety and patient safety incidents in the system. Part of what we want to do is utilise this information in a much more intelligent and informative way.

The issue was raised of insurers and their views. The State Claims Agency has been a signed up partner around the open disclosure policy for the HSE and was a signed up partner also for the evaluation. The agency has stated very clearly and publicly that it supports open disclosure and early interactions with patients when adverse events have happened, to support patients. That is a very helpful position in moving forward. The more we are all co-ordinated in that regard, the better traction we will get around the whole patient safety culture.