PUBLIC HOSPITALS KILL

A dehydrated child who waited four hours for treatment in a country emergency department was among 21 people who died through errors in Victoria's public hospitals last financial year. According to a report obtained by The Age, inexperienced staff failed to accurately monitor the deteriorating condition of the child, whose age and gender is not known. The report said that the busy emergency department of the unnamed hospital had no clear plans for the monitoring of young patients.

The case is one of 85 significant medical errors reported to the Department of Human Services in 2003-04 that are contained in the Sentinel Event Program report, obtained under freedom of information laws. The report details medical procedures on the wrong patient, procedures on the wrong body part, medication errors, infection control breaches and cases in which instruments or materials were left in patients after surgery. The other deaths involved 10 mostly elderly people who died after falls (three in hospital-run residential aged-care facilities), four people given the wrong drug or an incorrect drug dosage, two due to a catheter fatally damaging an artery in the heart during routine surgery, and two women dying during childbirth. Two patients - one had absconded - committed suicide.

The number of sentinel events - rare, clear-cut incidents that can have a catastrophic outcome for patients - was up slightly on the previous year, but it is regarded by experts as being only a fraction of the serious or deadly mistakes made by hospital medical staff. The figures do not include errors in private hospitals.

Department of Human Services chief clinical adviser Jenny Bartlett said the reporting of serious medical errors varied between public hospitals. "There are hospitals that have endorsed this program actively and supportively, and there are some hospitals that haven't grasped the benefit of contributing to system-wide improvement," she said.

The report said two non-English-speaking patients not given access to an interpreter had surgery on the wrong parts of their bodies. One had a cataract operation on the wrong eye, the other had an operation to remove a skin cancer on the wrong leg. Dr Bartlett said most of the 14 cases in which the wrong patient or wrong body part was operated on were for minor procedures. "We haven't had the wrong leg amputated," she said.

Four people died due to drug errors, including two patients who were given too much anticoagulant after heart surgery. Ten complications due to surgical errors included a case in which a patient's bowel was reconnected in the wrong place. Six complications due to anaesthetic management included a patient whose lungs collapsed after equipment broke down before a brain operation.

Instruments or gauze packs were left behind after eight operations. In one case, surgeons sewed up a woman after an emergency caesarean section despite a count that revealed one gauze pack was missing.

Two people hurt in car accidents were further injured when staff at country hospitals who were inexperienced in trauma cases failed to detect spinal injury in the neck. Dr Bartlett said significant inconsistencies in treatment of spinal injuries led to written guidelines being sent to each hospital.

The aim of reporting is to identify reasons for mistakes so that they are not repeated. Most errors were attributed to poor staff communication, problems with procedures and guidelines, or inadequate training.

Source

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