Reforms planned for SAI process - Swann

Date published: 07 July 2022

Health Minister Robin Swann has announced plans to improve the Serious Adverse Incident review process in Northern Ireland’s health and social care system.

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Serious Adverse Incident (SAI) reviews are initiated following unexpected and unintended incidents of harm. Their objective is to ensure service providers learn from harm and make improvements to services.

The Minister said changes to the process must promote a culture of safety, openness and compassion and deliver benefits for patients and their families.

He was commenting on the publication of a major Review of the Systems and Processes for Learning from SAIs in Northern Ireland, which was undertaken by RQIA.

The RQIA review identified shortcomings in the current SAI procedure and its implementation. It recommends that the Department of Health should work collaboratively with patient and carer representatives and the Health and Social Care system to design a new regional SAI procedure.

The review advocates an evidence-based approach for determining which adverse events require a structured, in-depth review.

The Health Minister said: “Every day, many people experience safe, high quality health and social care services delivered by highly skilled and dedicated professionals across our health and social care sector. However, when the care or treatment delivered does not meet expected standards and harm occurs, it is important that we identify what happened, understand how and why it happened and learn from it.”

This has been one of the most significant reviews undertaken by the RQIA, led by an Expert Review Team.

The Minister stated: “I want to thank the Expert Review Team for its comprehensive work and for its detailed engagement with all stakeholders throughout this review.

“I am committed to supporting the re-design and implementation of a new regional SAI procedure which ensures HSC staff, service users and their families are all supported as active partners in the review process.”

He added: “My Department will be guided by this important RQIA Report as it co-designs a new regional procedure.  This will support an improved approach to learning from reviews where harm has occurred, thus driving quality improvement and delivering safer services.”

The RQIA review cites a series of benefits that would be achieved through the adoption of its recommendations. These include:

• A clear regional framework which provides for learning from unexpected harm.

• Greater flexibility in the SAI review process, which is aligned to international best practice and allows a better opportunity for learning and improving safety.

• An appropriate amount of time to conduct a review well and to involve patients and families in a way that is meaningful.

• A review process that does not cause further harm to patients, their families or staff.

• A process that promotes a culture of safety, openness and compassion.

• A single, new report template and regional style guide that supports consistency writing across the region but is also flexible.

Notes to editors: 

  1. A copy of the report: RQIA review of the Systems and Processes for Learning from Serious Adverse Incidents in Northern Ireland, is available to download on the Department’s website.
  2. For media enquiries please contact the DoH Press Office by email
  3.  Follow us on Twitter @healthdpt
  4. The Executive Information Service operates an out of hours service For Media Enquiries Only between 1800hrs and 0800hrs Monday to Friday and at weekends and public holidays. The duty press officer can be contacted on 028 9037 8110.

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