http://sg.yfittopostblog.com/2010/11/05/new-rule-for-all-assisted-reproduction-centres/
Healthcare sector to learn from aviation industry: Khaw
By Alicia Wong – November 5th, 2010
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When the Qantas A380 plane had to make an emergency landing in Changi Airport, Qantas immediately suspended all A380 flights and Singapore Airlines followed suit.
Such measures show how the aviation sector as moved away from using a “largely fault-finding approach” in tackling safety and errors, to taking a “system approach” to probe for deeper issues within the system, said Health Minister Khaw Boon Wan.
This is what the healthcare sector should do, in the event of a mistake, such as a botched in-vitro fertilisation, he said in his blog on Saturday.
When Thomson Fertility Centre’s error in giving a couple the wrong sperm during an IVF was discovered, the Health Ministry took a system approach, said Mr Khaw, making his first public comments on this incident on Saturday.
He first spoke on the matter at the sidelines of a community event on Saturday, where he also stressed on the need to move away from witch-hunting, reported The Straits Times.
“In the United States, experts have estimated that errors in hospitals are hurting patients unnecessarily at the rate equivalent to one plane crash a day, or some such dramatic figure,” said Mr Khaw, adding that experts have concluded the healthcare sector should emulate the aviation sector’s approach to safety.
The latter, noted Mr Khaw, has moved away from fault-finding, an approach the aviation sector took 10 to 20 years ago.
“(Now) each time an adverse event occurs, they will conduct an objective and thorough investigation, not to witch hunt, but to identify the causes, especially if there are systemic flaws,” he said.
The result: Significant progress in raising safety and minimising mistakes in aviation, as people were open in their comments and there was fast and accurate assessments of the situation.
In the case of Thomson Fertility Centre, investigations started immediately, the centre’s IVF activities were suspended and arrangements were made for patients in the middle of their IVF programme, outline Mr Khaw.
Mr Khaw stressed, “We will get to the bottom of the problem. We will make a clear distinction between once-off human error and systemic flaws in the IVF operating system, with different follow up actions.”
If systemic flaws are identified, the ministry will share with the industry so a similar problem will not recur, he said.
And in the mean time, the priority remains on protecting the couple and their baby’s welfare, said Mr Khaw.
“It is heart-warming to read that the couple have bonded with the baby and will not allow this incident to affect their bond.”
On Friday, the Ministry of Health announced that all assisted reproduction (AR) centres will now be allowed to only handle one AR related specimen – for instance, sperm, oocyte or embryo – at a time.
The ministry also suspended Thomson Fertility Centre yesterday, with immediate effect, from conducting all new AR treatments.
Audits had revealed some shortcomings in its processes, such as a single laboratory personnel handling more than one specimen at the workstation in the laboratory at a given time.
“Thank you for the incredible, amazing response to Yahoo!’s Fit-To-Post blog so far. We continue to welcome your views and comments but please don’t abuse this opportunity. Be nice. Be courteous. Be sensible. Respect the feelings of others and refrain from using any kind of offensive language. And in the spirit of great conversations, please don’t stray from the topic at hand.”
Healthcare sector to learn from aviation industry: Khaw
By Alicia Wong – November 5th, 2010
Email Facebook Twitter Print
400afp_ivf
When the Qantas A380 plane had to make an emergency landing in Changi Airport, Qantas immediately suspended all A380 flights and Singapore Airlines followed suit.
Such measures show how the aviation sector as moved away from using a “largely fault-finding approach” in tackling safety and errors, to taking a “system approach” to probe for deeper issues within the system, said Health Minister Khaw Boon Wan.
This is what the healthcare sector should do, in the event of a mistake, such as a botched in-vitro fertilisation, he said in his blog on Saturday.
When Thomson Fertility Centre’s error in giving a couple the wrong sperm during an IVF was discovered, the Health Ministry took a system approach, said Mr Khaw, making his first public comments on this incident on Saturday.
He first spoke on the matter at the sidelines of a community event on Saturday, where he also stressed on the need to move away from witch-hunting, reported The Straits Times.
“In the United States, experts have estimated that errors in hospitals are hurting patients unnecessarily at the rate equivalent to one plane crash a day, or some such dramatic figure,” said Mr Khaw, adding that experts have concluded the healthcare sector should emulate the aviation sector’s approach to safety.
The latter, noted Mr Khaw, has moved away from fault-finding, an approach the aviation sector took 10 to 20 years ago.
“(Now) each time an adverse event occurs, they will conduct an objective and thorough investigation, not to witch hunt, but to identify the causes, especially if there are systemic flaws,” he said.
The result: Significant progress in raising safety and minimising mistakes in aviation, as people were open in their comments and there was fast and accurate assessments of the situation.
In the case of Thomson Fertility Centre, investigations started immediately, the centre’s IVF activities were suspended and arrangements were made for patients in the middle of their IVF programme, outline Mr Khaw.
Mr Khaw stressed, “We will get to the bottom of the problem. We will make a clear distinction between once-off human error and systemic flaws in the IVF operating system, with different follow up actions.”
If systemic flaws are identified, the ministry will share with the industry so a similar problem will not recur, he said.
And in the mean time, the priority remains on protecting the couple and their baby’s welfare, said Mr Khaw.
“It is heart-warming to read that the couple have bonded with the baby and will not allow this incident to affect their bond.”
On Friday, the Ministry of Health announced that all assisted reproduction (AR) centres will now be allowed to only handle one AR related specimen – for instance, sperm, oocyte or embryo – at a time.
The ministry also suspended Thomson Fertility Centre yesterday, with immediate effect, from conducting all new AR treatments.
Audits had revealed some shortcomings in its processes, such as a single laboratory personnel handling more than one specimen at the workstation in the laboratory at a given time.
“Thank you for the incredible, amazing response to Yahoo!’s Fit-To-Post blog so far. We continue to welcome your views and comments but please don’t abuse this opportunity. Be nice. Be courteous. Be sensible. Respect the feelings of others and refrain from using any kind of offensive language. And in the spirit of great conversations, please don’t stray from the topic at hand.”
