'A catastrophic failure of the incident management process.'
These are the words of the head of the HSE, Tony O'Brien, following the tragi-farcical events surrounding the Crumlin hospital colonoscope contamination scare this week.
If, in a spirit of misplaced generosity, we are to deal out any kudos to the health authorities following the latest patient safety incident and its somewhat eccentric handling, Mr O'Brien should at least be commended for distilling it to its essential element - omnishambles.
The hospital earlier this week informed 18 families that their children may have been affected by a bug found on a colonoscope. Unfortunately, it turned out the Crumlin had identified the wrong patients and the wrong colonoscope, causing a lot of unnecessary worry and prolonging the 'bad PR' for the hospital.
The hospital apologised (for the second time in a week) and said seven different families of child patients were now being contacted about the colonoscope contamination. Hopefully, they've got it right second time.
The HSE has now said that a review will take place into how the incident was handled by the the hospital. Until now the HSE appears to have taken a 'hands off' approach to this particular incident.
Our much criticised health service has, it could be argued, reached a new low when an incident management process is called in to investigate an incident management process.
Health Minister James Reilly, responding to the furore over the Crumlin incident, said: "I think we have to learn from this and make sure these sort of avoidable errors never happen again."
By now such statements must fall into the 'I can't believe he said that (again)' category.
How many times has the public been told in recent years, following the latest corporate apology, 'lookback' and helpline saga in healthcare, that that this type of thing won't happen again?
The truth is, patient safety incidents and their subsequent handling (or mishandling) tend to repeat themselves, first as tragedy then as near-farce. The Crumlin incident is of particular concern as in its earlier stages, the hospital did not appear not to know the true nature of the incident and who was affected by it.
Crumlin hospital has an unfortunate history recently with patient safety incidents.
In 2008, it assured the public that 'learning' following a serious incident where a child had the wrong kidney removed would be shared to improve patient safety.
Yet in 2010 it was issuing similar assurances when another child patient had incorrect surgery, this time an unnecessary 'tongue tie' operation.
And it is probably unfair just to pinpoint Crumlin. We have seen many safety lapses, poor incident management and hollow public assurances in other hospitals in recent years.
In late 2010, Tallaght Hospital, following the unreported x-rays scandal and an independent review report into this, promised us that patient safety safety would improve.
In 2011, two patients at the hospital died unexpectedly in an ED corridor- a safety scandal that was the subject of a HIQA investigation.
It still beggars belief that the HSE thought it was ok last November, following the scandal of Savita Halappanavar's death, to appoint doctors from the hospital department in which she died to investigate the circumstances of her death.
The latest incident, where a children's hospital failed in its duty to identify the source of a serious incident, quantify its ramifications and efficiently inform those really affected by it must call into question to what extent a proper patient safety culture is embedded in our hospital system.
And it also calls into question the extent to which the which hospitals who make serious clinical errors should be allowed investigate and follow up on these incidents themselves.
Going back to Mr O'Brien's comments on the Crumlin issue, he, rather aptly, said no amount of spin by PR companies (he was presumably referring to the fact that Crumlin was retaining a PR company to act for it ) could mask the seriousness of what had occurred.
This raises an issue about hospitals communicating (or not) with the public when a major incident occurs.
Late last week, it emerged that a patient at Dublin's Beaumont Hospital had recently been diagnosed with Creutzfeldt-Jakob Disease (CJD), and the hospital says it is now working to assess 'if any risk may exist for other patients' who may have been operated on with the same instruments used on the patient with CJD.
A serious incident indeed, but other than the bare facts above, the hospital (through a PR firm) and the HSE has released practically no information about it. The incident has been 'news managed' almost out of existence. Is it too cynical to suspect that this was the intention?
Notwithstanding the HSE/Beaumont's understandable concerns about patient confidentiality in a media-intrusive age, most reasonable members of the public would expect to be told exactly how many patients at Beaumont may be affected by potential contamination, and whether any children are affected (Beaumont is the main centre for carrying out neurosurgery procedures on children).
So far we have not been told this. It has so far not even been officially confirmed that the incident happened in the hospital's neurosurgery department, although it is widely known by now that this was where it occurred, or even what type of CJD is involved.
The official reason given for this excessive secrecy is possible threats to patient confidentiality. It is difficult to ascertain how, for example, revealing whether 15, or 18 or 20 patients were potentially affected by the incident could threaten patient confidentiality.
In this case, the public's right to know as much as possible about a serious incident, while taking into account reasonable confidentiality concerns, does not appear to have entered into the equation.
To date too, Beaumont has not provided a medical spokesperson to inform the public about the case.
Despite assurances from Minister Reilly that things will improve, there are serious fault-lines running through how our hospitals deal with preventing and dealing with patient safety incidents.
And the prospect of them getting more independence under his planned hospital trust system will necessitate some pretty convincing guarantees that safety will be maintained within these independent structures.
The public deserves rigorously-imposed national standards on all aspects of the management of clinical incidents, including proper communication with patients affected and the public at large.
Efficient implementation of these safety standards will only come about through a hospital licensing system, under which hospitals can lose their licences to operate if they do not come up the the mark.
Until such system is in place, the public will not be convinced that a patient safety culture is really embedded in our hospitals.
We're still waiting for this bright new dawn, Dr Reilly.
HSE chief slams Crumlin on bug blunder
Crumlin mixed up two contaminated scopes
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