A must to notify MOH of serious medical incidents

23 March 2013, Straits Times

Medical Errors and Near-misses : Ensure timely reporting

FROM the letter ("Grandma almost given wrong blood" by Madam Eileen Ang; March 14) and the report ("Given 1,000 times radioactive dose at SGH"; March 15), it is unclear if the Health Ministry was alerted when these incidents occurred.

I would be surprised if the ministry does not have any regulations that require all serious medical errors and near-misses to be reported to it within a stipulated timeframe.

The natural tendency of hospitals and clinics would be to keep such incidents quiet by settling the issue directly with the patients.

There are several benefits to having a law that requires all serious medical errors and near-misseswith potentially fatal consequences to be reported to the ministry.

First, it will ensure that all hospitals and clinics develop very robust control measures for all medicalprocedures with potentially serious or fatal consequences in the event of any errors or omissions.

It will also ensure that regular audits or independent reviews of such processes are conducted to minimise the risk of such occurrences.

Second, and more importantly, it will ensure that whenever a serious medical error or near-miss occurs, other hospitals and clinics will be able to learn from it.

The ministry can share the gist of the errors committed, along with an analysis of where the controls broke down and the lessons learnt.

It could then require all hospitals to declare that their corresponding processes are sufficiently robust, or that remedial actions are being taken to guard against the same errors .

Pua Hock Kee

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Reply from MOH

3 April 2013, Straits Times

A must to notify MOH of serious medical incidents

WE AGREE with Mr Pua Hock Kee ("Medical errors and near-misses: Ensure timely reporting"; March 23) and Miss Lee Soh Hong ("Vital to learn from medical errors"; last Friday) that patient safety is paramount in any health-care institution.

The Ministry of Health (MOH) takes a very serious view of any incident that may result in harm to patients.

It is imperative that our health-care institutions adhere to stringent protocols at all times and monitor the quality and outcomes of their care continuously.

Mr Pua had also noted that lessons should be learnt from such incidents to prevent similar occurrences.

We assure Mr Pua and Miss Lee that there is legislation in place that requires health-care institutions in Singapore to notify the MOH of serious reportable events.

In addition, hospitals are required to conduct an analysis to identify the causes of such incidents, and to put in place the necessary measures to prevent similar future incidents.

The ministry also facilitates the sharing of best practices through regular forums so that the health-care institutions can address system gaps to ensure patient safety.

Finally, the ministry also conducts regular audits and inspections to ensure that the institutions comply with the relevant statutory requirements.

We thank the writers for their feedback and for giving us the opportunity to explain the reporting of medical errors and near-misses.

Bey Mui Leng (Ms)

Director, Corporate Communications

Ministry of Health