This appeared last week:
Victorian hospital blunders led to 167 patient deaths
September 6, 2024 — 5.30am
A record 245 patients have died or suffered serious harm due to errors that unfolded at Victorian hospitals within a year.
Three patients died or suffered serious harm after surgery on the wrong part of their body, while four patients had foreign objects such as surgical sponges and dressings left inside them following surgery and other invasive procedures.
In one case, a woman who was admitted to hospital with a sore leg after falling off a step, developed blood clots in her lungs after being prescribed an inappropriate medication which left her on life-support.
The incidents are detailed in a Safer Care Victoria report published online last week, which revealed that approximately 167 patients died as a result of errors in Victorian hospitals in 2022-23.
It also documented several cases of missed testicular torsion that seriously harmed adolescent and young boys. These boys had arrived at emergency departments with acute abdominal pain.
In another case, a woman died after gastrointestinal complications caused by an antipsychotic medicine she was prescribed in hospital.
There were 245 sentinel events recorded in the state’s public and private hospitals in 2022-23, slightly more than the 240 incidents recorded the year before.
A sentinel event is an unexpected incident that leads to death or serious harm of a patient due to deficiencies in systems and process. This serious harm might involve a patient requiring life-saving surgical or medical intervention, shortened life expectancy or permanent or long-term loss of function.
Safer Care Victoria chief executive Louise McKinlay said sentinel events were tragic for patients, their families and hospital staff.
“These are terrible, catastrophic events,” she said. “No one goes to work to do harm but sadly things do go wrong.”
She said the stabilisation of sentinel events, following a sharp rise in previous years, indicated that the majority of incidents were now being reported. She said the data also illustrated improvements to transparency and the reporting culture of health services.
“This is not about blame,” she said. “It’s about understanding why did something happen and how do we stop it from happening again.”
Australian Medical Association Victorian president Dr Jill Tomlinson said sentinel events were more likely to occur when doctors were under pressure.
“Doctor’s don’t have ratios like nurses,” she said. “There can be very high workloads and unfortunately the more under pressure clinical staff are the greater the likelihood of avoidable harm to patients.”
She highlighted the recent coronial inquest into the preventable death of 19-month-old Victorian toddler Noah Souvatzis, who died on December 30, 2021, from meningitis. The coroner found that the toddler was discharged from Wangaratta hospital after an inadequate review by an under-trained, junior locum doctor on his first shift at the understaffed regional health service.
About one-third of the 245 incidents recorded in 2022-23 were for failing to recognise or respond to deteriorating patients. Issues relating to clinical process or procedure made up 24 per cent of cases, while medication errors were involved in 9 per cent of the incidents.
There was a slight decline in the number of sentinel events involving children, with 35 incidents involving them in 2022-23, compared with 38 children the year before. Around half of the incidents involving children related to patient deterioration.
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Shadow health minister Georgie Crozier said the numbers were not heading in the right direction and “much more needed to be done”.
“Our overwhelmed hospital emergency departments and other areas are clearly not coping if these numbers are rising, not decreasing,” she said.
Victorian Health Minister Mary-Anne Thomas said every sentinel event was a tragedy we needed to learn from.
“We are making significant changes to the way our health services respond to patient deterioration because we know this has historically, and unacceptably, been a significant factor in paediatric sentinel events,” she said.
Thomas said these changes included a new urgent helpline to ensure patient and family concerns are heard, the roll-out of standardised monitoring across all hospitals and a new 24/7 virtual paediatric consultation system.
The helpline, which was launched by Thomas last week, was announced last year after an almost doubling of sentinel events involving children.
It also followed advocacy from the parents of eight-year-old Amrita Lanka, who died in 2022 after arriving at Monash Children’s Hospital with myocarditis, an inflammation of the heart muscle.
Her parents resorted to asking the cleaners for help while Amrita deteriorated. She was struggling to breathe, had chest pain and a high heart rate, but doctors ignored or misinterpreted signs she was critically unwell.
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There are a lot of sad and unhappy stories here but the overall message I take from these sagas is that a mixture of actually seeing the patient and applying common sense to what you see will save much suffering. Clear-eyed assessment and recognition that all is not well is not hard and insisting on senior review of what is going on can save a lot of lives!!!!
The other message is that procedures and routines are developed for a reason and it is vital to follow them - counting swabs etc. - to maximise safety! Short cuts can kill!
It is the old story that any experienced clinician needs about 2 seconds with the patient to recognize all is not well – and if action follows much good can flow! Where trouble ensues is when the doctor does not actually see the patient and so is not exposed to see the subtle clues that reveal the serious trouble!
I reckon it only takes about a year of clinical experience to be able to quickly recognize all is not well and seek / initiate help / action. With many even less time is needed!
Basic lesson is to clamp eyes on the
patient and you will seldom, if ever, not do the right thing in terms of what
is needed next and how soon! No one should ever be embarrassed about asking for a senior review and the seniors should respond promptly!
David.
5 comments:
Let's see if I've got this right.
It is far more beneficial to examine and diagnose the patient there and then than to have access to a a health summary record that could be totally out of date because a patient's circumstances may have changed?
I though so.
Pity about that $3 billion that was spent on the PCEHR/MyHR and flushed down the drain.
I suppose it did keep a few bureaucrats off the street for a decade, so it wasn't a complete waste.
That’s a false dichotomy. it is more benficial to examine the patient there and then than just to have access to a health record, but there are cases where the health record is very significant. Typically, emergency doctors use numbers like 1 in 20 cases they see.
So the goal of the MyHR is not stupid.
So the goal of the MyHR is not stupid
So is the issue perhaps that those behind that goal could score in a brothal?
@September 10, 2024 7:37 PM
"So the goal of the MyHR is not stupid."
The goal of the MyHR was thrown out the window along with the concept of integrated repositories. It was supposed to integrate existing data, not be a dumb central dump of trivial summary documents and a few test results.
Even then, the goal of integrating a huge amount of irrelevant detail is questionable.
It seems simple - Does the MyHR meet its mission? If not, remove it, as it impacts the broader ecosystem. The underlying requirements might be valid, but an improper solution will simply prevent that mission's aim. Quibbling over indervidual attempts or features distracts from the difficult decisions needed. If it is on mission then progress. Nothing wrong with First Attempt In Learning.
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