This appeared a few days ago and has a rather stark message:
Major hospital blunders cause dozens of deaths across Victoria
By Aisha Dow
21 September 2018 — 3:49pm
More than 120 patients have died or suffered serious harm due to errors in Victorian hospitals in the past two years.
In one case, a person died after being administered a dose of medication 10 times higher than prescribed.
And three cancer patients had urgent colonoscopy procedures delayed as a result of administration errors, meaning their cancers were already well progressed by the time they were eventually discovered.
Called sentinel events, these major incidents fall into nine categories, including operating on the wrong body part, suicide in an inpatient unit, medication errors causing death, and babies being discharged into the wrong family.
Most of Victoria’s public hospitals detailed their rates of sentinel events publicly for the first time this week in their annual reports.
Monash Health had 10, Melbourne Health had nine, Eastern Health had seven and Mercy Hospitals Victoria had four.
The deaths also occurred in many rural and regional services, including Portland District Health, and South West Healthcare in Warrnambool, which both had three.
There were at least 58 sentinel events across the public sector - though the exact number is uncertain as St Vincent’s Hospital declined to release its figures.
Safer Care Victoria, which oversees sentinel event disclosures, said reports continued to rise as part of a concerted effort to get hospitals better to identify these serious events, and learn from them.
Although some hospitals are reporting higher rates than others, Safer Care Victoria chief executive Professor Euan Wallace said this did not mean these hospitals were more dangerous than others. Rather, they may simply have better processes in place.
“I would suggest that hospitals that are reporting sentinel events have a healthy culture of transparency and reporting,” he said.
While the circumstances of the most recent sentinel events were not revealed in the annual reports released this week, Safer Care Victoria does publish a yearly summary.
More commentary here:
https://www.smh.com.au/national/victoria/major-hospital-blunders-cause-dozens-of-deaths-across-victoria-20180921-p505a1.html
The thing is all these errors are pretty much in hospital human error which the myHR really cannot get to – although good hospital systems (medication management etc.) , barcodes etc. can help a lot.
While on the topic lets not forget about prescription drug abuse and the opioid overdose crisis which are sadly claiming an increasing number of lives. There are things digital health can add to help with this - e.g. RTPM - but the myHR is not one of them.
Here is a useful link on all that:
https://www.theaustralian.com.au/life/the-dope-on-pharmaceuticals-a-danger-to-the-people/news-story/81c22d397da7cd9e50b72ae47f58517b
It is important to look at all the claims of the ADHA critically and think just how much difference the myHR can possibly make in most situations. I am unconvinced it is all that much - and pretty much zilch in hospitals where sadly most of use will die. The myHR is no panacea for what ails us...
David.
2 comments:
Certainly raises the question. If a record is amended at a go or hospital that is already been sent to the GovHR, how is that handled? Is there a procedure in place to sanitatise the original record or is yet another record pinned to an ever increasing pile of files?
@September 26, 2018 5:00 PM
It is a common misconception that records that exist in a GP's system or hospital are copied to the myhr. All summaries are created for myhr and are then uploaded. If the data in a GP's system changes then the summary needs to be recreated and then uploaded to myhr. There appears to be some sort of mechanism for the original author to delete the earlier copy of the summary.
Re procedures, it is up to each institution to establish its own procedures.
myhr is a dumb document store which offers no assistance in creating or managing the data that is uploaded, or even once it has been uploaded.
ADHA does not provide much information about how the thing works or is supposed to be operated.
Have a look at this page and see if you can make sense of how hospital procedures relate to myhr.
"My Health Record in the hospital setting"
https://www.myhealthrecord.gov.au/for-healthcare-professionals/hospitals
If you want to know about editing documents, that page is useless, you have to go to "Upload clinical information, such as:" then click on "event summaries" which takes you to
https://www.myhealthrecord.gov.au/for-healthcare-professionals/event-summaries where there is some information on the topic.
you could also click on "eprescriptions" where you also find out about editing and this:
"The author of a prescription record can delete it from a patient's My Health Record if it has been uploaded in error or contains a mistake.
A prescription record cannot be edited once it is in a My Health Record, however they can be 'superseded' which means replacing the original with a new version. A prescription record is treated exactly the same as all other clinical documents in regard to deleting or superseding.
Note that when using ePrescribing and uploading prescriptions to the My Health Record system, the paper prescription remains the legal document. If you made an error on the prescription and manually edit the paper script after it has been printed, this change will not appear on the electronic version uploaded to the My Health Record or sent via the Prescription Exchange Service to the dispenser. In this scenario, you should ensure that the correct version of the electronic prescription is shared to the patient's My Health Record."
That's helpful.... NOT.
Here's a question: who is responsible and accountable for ensuring the data in myhr is consistent with that outside the system? AFAIK, nobody.
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