A formal clinical risk management process is required to improve patient outcomes when it comes to the treatment of sepsis, an Oireachtas committee has heard.
Chairperson of the Irish Sepsis Foundation – Doireann O’Mahony – said that a formal process of reviewing patient outcomes can potentially reduce further patient injury, and redress current shortcomings in medical audits.
“Risk management is supposed to provide the HSE with a structured approach to anticipate the threats that could occur, assist in identifying the most effective way to manage those threats, and provide the means by which the HSE can measure how successful it has been in its efforts,” she said in her opening statement to the Joint Oireachtas Committee on Health today.
“As we see it, the purpose of clinical risk management is to provide the organisation (the HSE) with a memory. Without remembering its shortcomings, the organisation is unlikely to improve.
“Such a system has at its foundation the reduction of cost to the organisation, but its primary purpose in health facilities is to improve the quality of care and the outcome for the individual patient, whose welfare is at the centre of the process. This individual is no longer identified as a potential litigant.
“We must remember that without the identification of fault, there can be no improvement in the standard of care. There can be no improvement without the identification and correction of fault. Without a proper system of risk management, nothing will change,” she added.
“We owe it to those who have been affected by sepsis to do better. To effect change we must formalise the mechanism for risk management.”
The committee also heard from Joe Hughes, whose son Seán died from sepsis in 2018, aged just 15. Seán had no underlying health issues.
“We never heard of sepsis before it took Seán from us,” Mr Hughes said. “Now we are doing all that we can to raise public awareness about the dangers of the silent serial killer called sepsis.”
The 2021 National Sepsis Report recorded more than 13,000 cases of sepsis and septic shock that year. Incidence was 10 per cent higher than 2020, with the report citing the Covid pandemic as a factor in the rise.
HSE chief clinical officer Dr Colm Henry said that ‘as the pandemic has waned, there have been some poorly understood changes in sepsis epidemiology, notably the global increase in invasive Group A Strep infections which we have also noted in Ireland’.
However, he noted that in-hospital sepsis mortality rates have continued to fall, from 20.3 per cent in 2020 to 19 per cent in 2021. “It is expected that data will be published for 2022 before the year end,” he added.