MOH Accepts Findings of the Independent Review Committee

Patient safety as the healthcare system’s highest priority

The Ministry of Health (MOH) has accepted the findings and recommendations of the Independent Review Committee (IRC) tasked to look into the cluster of Hepatitis C cases at the Singapore General Hospital (SGH)’s renal ward. The IRC submitted its report to MOH on 5 December. MOH has also extended a copy of the report to SGH.

2.            The report laid out the likely chain of factors contributing to the outbreak and recommended measures to close the gaps in infection control practices. It also reviewed the overall timeliness and appropriateness of the response of the healthcare system in managing the Hepatitis C cluster.  

3.            The findings are a timely reminder not just for MOH and SGH, but also for the entire healthcare community of the need to remain vigilant. Our patients’ safety is paramount. We are sorry that these lapses occurred.

Rectifying gaps in infection control practices

4.            Healthcare institutions are required to have infection control protocols in place and to have robust measures to ensure compliance. All healthcare professionals are expected to comply with these protocols, to ensure patient safety and wellbeing at all times. To provide a safe environment for our patients, MOH conducts regular audits and inspections of healthcare institutions to ensure that they have put in place procedures for infection control and other areas pertaining to patient safety and patient care.

5.            MOH accepts the IRC’s recommendations concerning the areas for improvement in the infection control practices in SGH’s renal ward, and will work with the SGH management and staff to ensure that the gaps are addressed.  

Enhancing the surveillance, investigation and management of outbreaks

6.            The IRC has noted that the current national surveillance system works well for detecting community outbreaks of known infectious diseases, and hospitals also have robust frameworks to deal with common healthcare-associated infections (HAIs). Hospitals take responsibility for the investigation and management of typical HAIs as they are the most familiar with their own operations. MOH has a quality assurance framework where institutions are required to report common HAIs and other patient safety indicators to MOH for wider sharing and learning, and exchange of best practices.

7.            However, the Hepatitis C virus (HCV) outbreak has highlighted a gap in the current system. As an unusual HAI with unique characteristics, HCV is not easily picked up through regular surveillance. Within MOH, there was also no designated division with the responsibility and capabilities to deal with an unusual HAI like HCV.  These resulted in delayed recognition of the HCV outbreak by SGH, and delayed escalation from SGH to SingHealth, from SGH to MOH, and within MOH.

8.            MOH agrees with the IRC’s recommendation that hospitals should continue to take responsibility for HAIs and enhance structures, frameworks and capabilities for HAI outbreaks within their institutions. To supplement these efforts, MOH will strengthen national resources and capabilities to support hospitals and other healthcare institutions in the management of outbreaks. 

9.            To address the various recommendations of the IRC, MOH will set up a taskforce led by Mr Chee Hong Tat, Minister of State for Health, to enhance the national healthcare system’s ability to detect and respond to infectious disease outbreaks in hospitals and the community.  More details on the scope and composition of the taskforce will be released shortly.

10.         In the meantime, MOH has put in place measures to strengthen our capability to detect potential outbreaks in Singapore. This includes designating the Communicable Diseases Division to be responsible for overseeing surveillance of all infectious diseases, and centralising all notifications, analyses of infectious disease data.

11.         We have also taken initial steps to improve the notification and surveillance system for acute HCV. MOH has improved the notification process for HCV, as recommended by the IRC. All healthcare institutions have been reminded to notify all acute infections to MOH, even though the laboratories will separately inform MOH of their test results.

12.         As we seek to enhance the management of unusual outbreaks within hospitals and at MOH, we agree with the IRC that regardless of the systems in place, alert healthcare professionals are still key to identifying that something might be amiss.

13.         MOH notes that the IRC had found no evidence that SGH or MOH staff deliberately delayed escalating the outbreak or in informing the Minister for Health. The IRC agreed that the decision of the DMS on 3 September to ask SGH to complete key pieces of investigation was professionally appropriate and valid.

Learning for the healthcare community

14.         MOH would like to put on record our appreciation to the Independent Review Committee and its Chairperson, Professor Leo Yee Sin.  The IRC’s investigation has been thorough and objective, and was facilitated by the full cooperation from the management and staff of MOH and SGH.  

15.         This outbreak holds valuable lessons for our national healthcare system.  It is a timely reminder that while our healthcare institutions may have systems and protocols in place, healthcare professionals must remain vigilant at all times, especially when faced with unusual and unfamiliar events.

16.         MOH will study the IRC’s findings and recommendations carefully, glean learning points and put in place measures to close gaps and improve the healthcare system as a whole. We will share the findings with healthcare institutions to ensure sector wide learning. We will also set up a human resource panel to examine the roles, responsibilities and actions of key MOH staff, and assess if disciplinary actions need to be taken.

17.         Even as we work to improve the system as a whole, our thoughts are with the affected patients and families.  We apologise to the patients and their families who have been affected by the outbreak.  For the families who have lost their loved ones, we extend our deepest condolences.  We will continue to work with SGH to ensure that the affected patients and their families receive the necessary support and care to manage their conditions.

MINISTRY OF HEALTH

8 DECEMBER 2015