Learning from mistakes, not a blame culture, the way forward for hospitals: Gan

SINGAPORE — Amid calls for more details on the identities of, and punishments for, 16 Ministry of Health (MOH) and Singapore General Hospital (SGH) employees involved in the hepatitis C outbreak last year, Health Minister Gan Kim Yong said the important thing to do is to learn from the mistake to prevent a repeat.

“Instead of naming the individuals and developing a blame culture in our healthcare institutions, we need to encourage a learning culture to make our hospitals as safe as possible for the patients.

“This culture of continual learning and improvement is important for enhancing patient safety and the quality of care,” said Mr Gan in Parliament on Monday (April 4). He was responding to Non-Constituency Member of Parliament Leon Perera, who asked for the names of these individuals, and how and why each was punished.

“Revealing the names of the officers and specific sanctions each individual received does not contribute to better care of patients. In deciding what to disclose, we have to bear in mind the longer-term impact on our healthcare system and healthcare workers, and strike a careful balance,” the minister added.

The outbreak in SGH’s renal ward affected 25 patients, of which eight have since died. The first case was diagnosed on April 17. The outbreak was first made public almost six months later, on Oct 6.

A report submitted by an independent review committee last December found that multiple overlapping factors, including gaps in SGH’s infection prevention and control, had most likely caused the outbreak, which occurred between April and August last year.

The report also concluded that SGH had failed to recognise the outbreak in a timely manner.

In an update last month, the MOH said it had warned, sternly warned and fined four senior executives — who were at director-level or equivalent. The disciplinary action taken against these employees were for their failure to intervene early and ensure the infectious disease notification and reporting system was effective and rigorous.

SGH said it sternly warned and fined 12 employees — including senior management members — for their failure to enforce a strong infection-control regime and incident-escalation protocols within the hospital.

On the penalties, Mr Gan said on Monday that a warning would be lodged in the staff’s service record, while a stern warning has a “negative bearing” on one’s career, affecting future promotions and awards. A warning and a stern warning may each be issued with a fine.

Moving forward, the focus lies in improving systems and processes to enhance infection control, and strengthen detection and response to infectious diseases, said Mr Gan.

Following the release of the report, SGH has boosted infection-control practices by stepping up cleaning and decontamination of potentially contaminated surfaces.

The hospital has also improved its education and training programmes for staff, and implemented stricter monitoring of infection-control

practices.

Apart from these, the hospital has also brought in consultants from Joint Commission International, an accreditation and consultancy organisation, to review and assess the hospital’s clinical processes.

“We are also sharing the lessons learnt from this outbreak with all hospitals, and working with them to ensure that their infection control, risk management and escalation protocols are in place,” said Mr Gan.

The minister also stressed that the MOH and SGH are committed to care for all affected patients through counselling, support and hepatitis C treatment.

“Once again, let me apologise to the affected patients and their family members for this incident, and especially to those who lost their loved ones,” he added.