Robin Swann, Health Minister of Northern Ireland, has made plans to improve the process for reviewing serious adverse events (SAIs) in Northern Ireland's healthcare and social care system.
These reviews are done after unintentional incidents of harm, and they ensure that improvements are made.
To assess the effectiveness of the system, the Regulation and Quality Improvement Authority (RQIA), was created.
It concluded that the process was not sufficiently robust.
After the public inquiry into deaths in Northern Ireland hospitals of five children, the report on learning systems and processes after an SAI was completed.
Four deaths could have been avoided, according to the hyponatraemia inquiry that lasted 14 years.
The RQIA report, published Thursday, found that neither the SAI review process nor its implementation are sufficiently robust to allow for a consistent understanding of the factors that have caused a patient to become ill or a service user to be harmed.
The statement continued: "The truth is that similar situations where events leading to harm were not adequately investigated and examples of recognized good practice haven't been followed have been repeated and will continue to be in current practice."
It found failures in the SAI process, including failures to:
The report suggested a regional SAI procedure as well as an evidence-based approach to determine which adverse events require in-depth reviews.
Other recommendations include conducting reviews within a "fairly reasonable" timeframe and including families and patients.
Swann stated that changes to the system should promote safety for patients and their families.
Swann stated that "Everyday, many people receive safe, high-quality health and social services delivered by highly skilled, dedicated professionals in our health care and social service sectors."
"However, when care or treatment is not up to standard and harm occurs, it's important that we understand what happened and how it happened so that we can learn from it.
He said, "My department will be guided through this important RQIA Report as it co-designs the new regional procedure. This will allow for a better approach to learning from harm reviews, thereby enhancing quality and delivering safer services.
