We asked numerous doctors and nurses if they’d heard of IRIS – none had.
We couldn’t access IRIS through the NSW Health Intranet.
IRIS is hidden, disconnected, and consequently ineffective. This is unfortunate given it is vital for patient safety.
IRIS stands for Incident Reporting & Investigation System – the Therapeutic and Goods Administration (TGA) rely on it to review medical equipment. The TGA are the only regulatory body in Australia who can effectively remove hazardous products from our hospitals.
Front line staff are well aware of their own states incident reporting systems (IIMS in NSW, VHIMS in Victoria, CIMS in WA, SLS in SA).
However, we’ve become aware that statewide incident reports aren’t forwarded to the IRIS system – this is a great concern.
Their decision not to ban indistinct chlorhexidine is heavily based on lack of reports in their IRIS system. They go on to cite several policies indicating how to avoid inadvertant injection (see here).
We’ve started contacting state reporting systems requesting a database review for cases of accidental chlorhexidine administration. We’ve discovered new cases of arterial injection, intravenous PICC line injection, and accidental administration into a cerebral ventricular drain. We’ll forward these to the TGA.
We hope the TGA recognise IRIS is desperately impaired and develop links with other reporting systems.
Just as seat belt laws didn’t lead to an increase in unsafe driving, introduction of safety measures won’t make healthcare staff less likely to follow policies.
Front line staff want to work in an environment safe for patient care. Over 250 people have signed the petition to ban indistinct chlorhexidine (sign here).
Your support is driving change – Sydney Local Health District has replaced indistinct chlorhexidine with a more distinct solution – we hope others will follow suit.
Patient safety may improve when:
– we accept an error by one person is something we could all make,
– we learn how to effectively prevent these errors leading to adverse outcomes
– and we have the tools to put this learning in place.