Ministry of Health reminds Healthcare Institutions (HCIs) to safeguard and ensure patient safety

           The Ministry of Health (MOH) has received from KK Women’s and Children’s Hospital (KKH) the report by the Review Committee chaired by Professor Ho Lai Yun,Senior Consultant, Department of Neonatal and Developmental Medicine, Singapore General Hospital. The Committee was tasked by KKH to look into the recent incident where two babies were discharged to the wrong parents.

2          MOH has noted the findings of the Review Committee that the incident at KKH had occurred due to a lack of compliance with established procedures to ensure the right tagging and identification of babies with their mothers.

3          Safeguarding patient safety in healthcare is the topmost consideration for our healthcare institutions, and patient identity is integral to patient safety. Having the necessary systems, structures and processes is an important first step. Safety is ensured on a daily basis only if a culture of patient safety is pervasive and practised as a matter of habit. The lapse in KKH reveals that more work needs to be done to root and reinforce this culture of safety across the organisation and in all of its activities.

4          KKH’s leadership will need to take all necessary steps to close gaps, and to make improvements to ensure a pervasive culture of patient safety, supported by rigorous processes, including the conduct of periodic audits to check for compliance. The lapse is unacceptable and MOH has written a stern letter to the CEO of KKH to register its disappointment and concern on the lack of supervision and oversight, especially with regard to patient identity and safety in the nursery. KKH must take appropriate remedial actions to address the shortcomings disclosed through this incident, and also establish and maintain robust systems, processes and structures to address all major patient safety areas. MOH has also directed the Chairman of KKH’s Patient’s Safety Council to step up the Council’s oversight of ensuring patient safety and compliance by the staff, with a focus on patient identification as a bedrock for its work on patient safety.

5          The Ministry has also thoroughly reviewed the recommendations from the Committee as well as the additional recommendations by KKH. These  recommendations cover improvements such as patient care and ward processes, staff education, protocol compliance and supervision, governance, as well as IT enablers. The hospital has already implemented most of these recommendations and is also evaluating possible IT solutions that could further strengthen the current manual processes.

6          MOH notes that KKH had taken disciplinary actions against the respective staff who were responsible for the incident, and their supervisors. The staff had also personally apologised to the affected parents.

MOH’S INSPECTIONS ON HOSPITALS

7          Following the incident, the Ministry’s officers also inspected both public and private hospitals in late November to appraise the policies, structures and processes of tagging and verifying babies' identification after deliveries. All hospitals that were inspected were assessed to have adequate policies, structures and protocols coupled with appropriate measures in place to safeguard babies' safety.

8          Follow-up inspections were also carried out in early December in both public and private hospitals to ensure that staff adhere to the policies, processes of tagging and verifying babies' identification during the peak periods of shift change, feeding and bathing.

MOH REMINDS HCIs TO STRENGTHEN QUALITY ASSURANCE PROGRAMMES TO IMPROVE PATIENT SAFETY AND OUTCOMES

9          Said Director of Medical Services, Prof K Satku, “Quality assurance activities have been ongoing in our hospitals and healthcare institutions have been working to improve patient safety and outcomes. In 2011, the Ministry issued a directive under the Private Hospitals and Medical Clinics Act, specifying 27 serious event categories for which institutions should establish and maintain ongoing quality assurance programmes. The unfortunate incident at KKH falls within one of these 27 categories - ‘Discharge of Infant to the Wrong Person’. This should be a reminder to all healthcare institutions in Singapore to strengthen their quality assurance programmes to improve patient safety and outcomes. MOH will work with all healthcare institutions to ensure appropriate follow up in this respect.”

MINISTRY OF HEALTH

26 DECEMBER 2012