A public consultation has opened on the redesign of the current Serious Adverse Incident (SAI) procedure in Northern Ireland.
The consultation is asking for views on a new draft Regional Framework for Learning and Improvement from Patient Safety Incidents and supporting documentation.
The SAI review process is intended to play an important role in securing improvements in the quality and safety of health and social care (HSC) services by ensuring that incidents are identified, reported and investigated as appropriate so that learning can be shared across the HSC system.
However, while there is undoubtedly good practice across the HSC in undertaking SAI reviews, there is clear evidence from inquiries and reports – including the Regulation and Quality Improvement Authority (RQIA) Review of Systems and Processes for Learning from Serious Adverse Incidents (SAIs), the inquiry into Hyponatraemia-related Deaths (IHRD) report and the Independent Neurology Inquiry - that aspects of the current SAI procedure need to be refreshed and redesigned.
Health Minister Mike Nesbitt said:
“I believe it is essential that the voices of all those affected are at the heart of the Patient Safety Incident review process and their experiences must be sought out and valued as trusted sources of information on patient safety, and as partners in service delivery.
“Equally, our staff must be able to voice their views, ideas and concerns without fear. Supporting an environment that welcomes, encourages and seeks out patient and staff experience is not only the right thing to do, but the essential thing to do in delivering continuous improvement to the delivery of care and ensuring better outcomes.”
The Minister acknowledged that significant cultural change is also required to move towards an open, honest, learning culture.
“I do not underestimate the magnitude of this task and recognise that cultural change takes time and is a continuous process,” the Minister added.
“Part of this process is to attempt, once again, to build confidence in the integrity and openness of the Health and Social Care system and I would encourage everyone to engage in this consultation process and help progress the redesign of the Serious Adverse Incident procedure in a way that is really going to have a positive impact.”
Some of the key aims of the new draft Framework include:
Providing a more streamlined and simplified process for reviewing Patient Safety Incidents, to ensure reviews are of a high quality;
Place all those affected at the heart of the process;
Focus on understanding how and why a Patient Safety Incident has occurred to identify system-wide learning leading to demonstrable and sustainable improvements in care.
The Framework will form part of a wider policy agenda to support an open, just and learning culture throughout HSC settings.
The consultation will close at 5pm on 6 June 2025.
Consultation documents and details on how to respond can be accessed at here.
The development of the draft Framework and supporting documentation has included collaboration and extensive engagement with a number of key stakeholders including those with lived experience of the extant procedure, relevant professional officers, Health and Social Care (HSC) Trusts, other nations and other statutory bodies from across Northern Ireland.
The Department has listened to and considered the views of stakeholders when setting out the draft proposals.