Medical Error Statistics- In the NEWS

27.12.07

S.A: Complaints against Doctors soar

20.12.07

VIC: AVOIDABLE hospital catastrophes killed 38 Victorians in the past year. REVEALED BY DHS SENTINEL EVENT PROGRAM, ANNUAL REPORT 2006-07

The deaths are a third higher than a year ago, and the highest recorded since the State Government set up the Sentinel Events Program five years ago.  Non-fatal cases included: A patient who had a swab sewn into his chest during heart surgery and had to undergo an operation to remove the gauze. A crash victim given the wrong blood during resuscitation. The blood was meant for a patient in an adjoining bed. Twenty other errors involving surgery on the wrong patient or body part were reported. Instruments or other materials were left in eight patients. Three patients died from medication mix-ups. Key causes were flawed procedures (32 per cent), poor communications (18 per cent), human error (15 per cent) and poor health information (12 per cent).

Source: news.com.au 21.12.07; The Age 21.12.07.

NSW: Royal North Shore Hospital

A REPORT released yesterday reveals more than 500 mistakes at the Royal North Shore Hospital have lead to either serious injury or death to patients. Source: news.com.au 20.12.07.

06.10.07

QUEENSLAND: 38 more patient deaths

QLD: a health watchdog is investigating the deaths of 38 patients believed to have died from negligence or catastrophic failures in the medical system. Medical staff are facing criminal prosecutions over two of the deaths. The deaths were among 5067 complaints fielded by the independent Health Quality and Complaints Commission in its first year. Source: news.com.au 06.10.07.

10.07.07

Report shows Australian public hospital bungles are killing scores of people

According to the Australian Institute of Health and Welfare in 2004-05:

- 53 operations were performed on the wrong part of the body.

- 27 patients who had operations, had instruments, sponges etc left inside their bodies.

- 7 patients died from being given the wrong medication.

- Missing medical records or ambiguous or illegible documentation about a patient led to 35 of the errors and 32 were caused in part because of poor communication between staff or between staff and patients.

- The institute said staff factors including inadequate training contributed to 23 of the errors, and 54 occurred in part because of problems with or breakdowns in rules, policies and procedures.

- 5 mothers died due to avoidable errors during childbirth

- Australian hospital patients needlessly died or were put at serious risk at least 130 times.

Patient safety expert Stephen Bolsin said little had improved in the past decade.

"Safety breaches in Australian healthcare are killing more people than breast cancer or road accidents," Associate Professor Bolsin said. (Source: SMH 11.07.07)

21.04.07

26.01.07

MEDICATION errors at Royal Melbourne Hospital have doubled in the past four years.

Melbourne Health, which runs the hospital, recorded 1217 medication errors in 2005-06 compared with just 503 in 2002-03.

Medication errors affected 1.2 per cent of the total number of patients treated at the hospital in 2005-06, compared with 0.6 per cent in 2002-03.

Melbourne Health also received its highest number of complaints in 2005-06, with 815 -- up from 603 in 2004-05.

(Herald Sun, 26 January 2007) ; [Melbourne Health Quality of Care Report 2005-06]

21.12.06

Harmed in NSW hospitals: 500 medical errors a record

ALMOST 500 medical errors in NSW public hospitals either seriously harmed patients or could have done so in 2005-06 - the highest number in the three years the statistics have been collected.

Sydney Morning Herald 21.12.06

Clinical Excellence Commission

18.10.06

Call to probe all maternal deaths
Coroners should investigate every death of a woman during pregnancy or childbirth, says a medical adviser Associate Professor James King, to the State Government.

A report by the Australian Institute of Health and Welfare shows there were 95 maternal deaths between 2000 and 2002, a rate of 11.1 women in every 100,000 who gave birth. This was up from 8.4 per 100,000 women in the previous three years.

The report said that of the 95 maternal deaths, 84 were related directly or indirectly to the pregnancy's management.

(The Age 18 October 2006) [AIHW: Maternal deaths in Australia 2000-2002]

05.10.06

Medical Errors in Victoria: 29 deaths connected to medical errors

A patient given the wrong dose of a sedative was among 29 people who died because of errors in hospitals that were reported to authorities last financial year.

The nurse administering the drug was unfamiliar with it and was not being supervised, according to State Government documents. When the medication error was identified, there was a delay in contacting medical staff.

The 29 deaths are among 91 serious medical errors that Victorian hospitals reported in 2005-06. The incidents are referred to as "sentinel events" and are defined as relatively infrequent, clear-cut events that reflect deficiencies in hospitals. There were 25 cases reported in which a procedure involved the wrong patient or body part, and six cases of instruments or other material being left inside patients, requiring more surgery to remove them. Medication errors led to the deaths of two patients. Seven medication errors did not result in deaths.

But the 91 incidents are believed to be a fraction of the serious errors in hospitals, many of which go unreported. While the number is lower than the 122 incidents, including 34 deaths, that hospitals reported in the previous year, authorities say that does not necessarily mean the true number of errors has gone down.

(The Age, 5 October 2006)

29.09.06

Patient deaths report transparency urged

(ABC News, 29 September 2006)
[The Second WA Sentinel Event Report 2005-2006 [pdf 759kb]]

30.08.06

BAD MEDICINE

Another week, another appalling medical misadventure ... Why the hospital system is in crisis and what must be done to protect us. Julie-Anne Davies reports. (Bulletin, 30 August 2006)- excellent article. Excerpts from this article-

Just last week, it was revealed that up to six people in northern NSW may have died because a pathologist misdiagnosed their tests, and another 38 received the wrong treatment for a range of diseases, including cancer. Incredibly, Hunter New England Health waited eight months before investigating Dr Farid Zaer, who had already been sacked by another area health service. Only days earlier we learnt that Sydney doctor Suman Sood, who was convicted of two counts of unlawfully giving abortion drugs to a young woman, had a history of complaints, investigations and legal action against her. In the wake of the disaster – and as many as 87 patient deaths – that marked Dr Jayant Patel’s two-year career at Queensland’s Bundaberg Hospital, are we any closer to properly policing incompetent or downright dangerous doctors?

Shirley Byrne should not have died. In medical terms, the 74-year-old Manly grandmother’s bowel cancer was unremarkable, and the surgery to cure it routine. But by the time she was wheeled into the recovery room at Ryde Hospital, in Sydney’s north-west, around 5.30pm on February 4, 2000, she wasn’t breathing and nurses could detect no pulse. Her heart had stopped beating.

For more than half an hour her anaesthetist, Gerrit Reimers, refused pleas from nurses to begin resuscitation. By the time another doctor arrived and took over, it was too late. She suffered severe and irreversible brain damage and died three days later. As a Medical Tribunal later found, Reimers’ actions had “at least” contributed to her death, describing them as a “gross departure from appropriate standards of conduct”.

As part of a broader investigation prompted by Byrne’s death, Reimers was found guilty of 13 counts of professional misconduct, which included stealing and self-administering the powerful opioids pethidine and fentanyl, and treating patients while under their influence. The complaints, brought by the NSW Health Care Complaints Commission, spanned from 1996 to 2000 (when he was suspended from practice) and involved nine patients at a number of Sydney hospitals.

Valmai Kilmartin, a 69-year-old woman who died at a Melbourne hospital three years ago, after a nurse accidentally injected her with lethal potassium chloride instead of saline. The drug vials looked almost identical. The tragedy had happened before, with at least two other deaths in similar circumstances in Victoria alone since 1992. In 1995 Johnstone recommended that changes to packaging be introduced. It was ignored. Finally, following Kilmartin’s death, the drug manufacturers redesigned the ampoules. Too late for Roy Kilmartin, though. In a humbling submission to his wife’s inquest, he summed up in a few words what Johnstone says he has spent his working life attempting to articulate.

29.08.06

Medical errors 'killing thousands'

The number of deadly errors occurring in Australian hospitals has probably not changed in the past decade, despite reforms and millions of dollars being thrown at the problem, an expert says.

Report author, Dr Ross Wilson says that ten years later, in all likelihood, the figures are the same.

(SMH/AAP, 29 August 2006)

26.08.06

System error reports ring early alarm bells

Crunching the numbers on what goes wrong in hospitals is giving safety experts a useful means of making medicine safer. Excerpt from article by Adam Cresswell, The Australian.

The Clinical Excellence Commission was launched in August 2004 and began encouraging doctors, nurses and other health care workers throughout the state's health system to notify any adverse events. These are broadly defined as any negative events - not merely those that harm patients, but also those that have the potential to cause harm but are detected in time. Even reports of lost property and complaints about staff rudeness are included in the count.

Because the Incident Information Management System (IIMS) started getting going mid-way through the 2004-05 year, the full-year figures did not reflect the true experience. The year just ended, 2005-06, was the first 12-month period for which full data was available (although, as the notification to the system is voluntary, the true level of incidents is almost certainly higher).

An analysis of that first full year's data showed there were at least 125,000 notifications of adverse events, about 70 per cent of which (88,000) were clinical - in other words, excluding the category that includes lost property and administrative matters.

About 18,750 incidents resulted in some level of harm to patients. The biggest category of incidents was falls, representing 26 per cent of all notifications - 32,500 incidents. Twenty per cent occurred in a geriatric unit, and 18 per cent and 14 per cent in a general medicine unit and rehabilitation or stroke unit respectively. Over half (65 per cent) of the patients were aged 70 to 95, and 70 per cent either tripped, slipped or lost their balance.

The next biggest was medication errors. In many cases, as with all the categories of adverse events, the error was at the less serious end of the spectrum. An example would be where a patient was given a painkilling drug a few hours later than scheduled, which might leave the patient with inadequate pain relief for a period but would not cause any long-term damage.

Potentially more serious examples include the patient being given the wrong dose, or being prescribed the wrong drug altogether.

Medication errors accounted for 18 per cent of notifications, or 22,500 incidents. Powerful painkilling drugs such as morphine and oxycodone were most commonly involved in adverse incidents, followed by the heroin substitute methadone, insulin, the blood-thinning agent warfarin and the common painkiller paracetamol.

However, serious adverse events - those resulting in serious harm or death - are relatively rare. Hughes says there were about 500 a year, although the precise figure from the latest data is still being extracted.

Earlier attempts to identify specific numbers of serious events were able to quantify how often the most serious types of mistakes or accidents occurred.

There were 13 procedures involving the incorrect patient or body part in 2003/04, and 14 the following year. This might involve a patient having an operation of the wrong part of their body, for example on the left side instead of the right or vice-versa; but it also might be a patient being taken for an X-ray that was intended for another patient, or the scan being taken of the wrong place.

Another category, "retained instruments or other material after surgery", shows how the figures are being used to find problems and fix them.

It refers to scenarios where equipment such as scissors or swabs are accidentally sewn up inside a patient after an operation. There were nine such instances of this in NSW in 2003-04, and five in 2004-05.

23.08.06

The response of doctors to a formal complaint
Louise Nash, Bradley Curtis, Merrilyn Walton, Simon Willcock, Christopher Tennant
Australasian Psychiatry 2006 14:3 246 [Abstract]

21.08.06

18,000 patients in NSW harmed by hospital mistakes

Source: Adam Creswell- The Australian

THOUSANDS of patients a year are being harmed by often avoidable mistakes such as being given the wrong drugs, incorrect treatment or falling down while in the care of public hospitals or other parts of the health system.

An analysis, to be released today, of the first full 12 months of data from a NSW program designed to encourage reporting of so-called "adverse events" has found there were 125,000 notifications in the year to July 2006, of which 18,750 resulted in some level of injury or harm to patients.

NSW accounts for about one-third of the healthcare episodes across Australia, so on a national basis the figures could be expected to be three times higher.

NSW accounts for about one-third of the healthcare episodes across Australia, so on a national basis the figures could be expected to be three times higher.

But because reporting events to the system is voluntary, the true level of mistakes and problems in the public hospital system is likely to be higher still.

Falls represented the biggest category of adverse events, accounting for 26 per cent of all notifications or 32,500 incidents. Medication errors -- patients given the wrong drug or the wrong dose -- came next, accounting for 18 per cent of notifications or 22,500 incidents.

Incorrect clinical management -- in cases where the patients' conditions may have been misdiagnosed, diagnosis was delayed, or the wrong treatment given -- accounted for 13 per cent of notifications, or 16,250 incidents.

The figures were compiled by the NSW Clinical Excellence Commission, whose CEO Cliff Hughes will present some of the findings at today's Australasian Conference on Safety and Quality in Health Care in Melbourne.

Professor Hughes told The Australian that all but about 400 to 500 incidents a year resulted in minor or no harm to the patients. About 37,000 of the 125,000 notifications were of a non-clinical nature, such as lost or stolen property, or complaints over how a patient was spoken to.

However, he conceded many incidents could be prevented by better hospital procedures, and said the data was being used to change the times at which some common yet potentially dangerous drugs were given.

An example was the blood-thinning drug warfarin, which is commonly used to reduce the risk of strokes and heart attacks or for patients with irregular heart rhythm. Too large a dose could cause haemorrhage, while too small a dose meant the drug would not work, Professor Hughes said.

For historical reasons, such as the fact the results of blood tests ordered in the mornings would only be available in the evening, warfarin was usually given to patients at about 8pm to 9pm. But the figures showed a three-fold spike in adverse drug events at about that time.

NSW was changing procedures to have the drug administered at about 4pm, when more staff would be on duty to monitor effectiveness and handle adverse consequences, he said.

"That's a pretty good example of how this data can be used to drill down and look at the trends, and make changes in healthcare to make it safer for patients."

Professor Hughes said analysing the figures showed inadequate knowledge or skills on the part of doctors or nurses was linked to about 56 of the 500 or so serious adverse events. Over three times more (170) were due to communication issues -- for example, when key details about the patient's condition were not transferred to another ward or hospital department.

"Any adverse event is the end-point of some deficiency in the system," Professor Hughes said.

Source: Adam Cresswell, The Australian online.

18.08.06

'Culture of Medicine,' Not Fear of Malpractice, Prompts Physicians To Withhold Information About Medical Errors From Patients, Study Says
Physicians often fail to inform patients about medical errors because of the "culture of medicine," rather than because of concerns about malpractice lawsuits, according to a study published on Monday in the Archives of Internal Medicine, the Seattle Times reports.(Daily Health Policy Report, 18 August 2006)

26.07.06

Key to cutting medical errors

IN May, the The Australian reported that "senior doctors claim teaching hours for anatomy have been slashed by 80 per cent in some medical schools to make way for touchy-feely subjects such as cultural sensitivity, communication and ethics". The report stated that the Australian Doctors Fund had lodged a 70-page submission with the federal Department of Education, Science and Training "listing arguments from more than two dozen professors, consultants and medical academics for a rethink on medical education".

Although a reassessment of anatomy and other basic science teaching may well be valuable, it will be regrettable if this leads to a down-grading of education in effective communication for future doctors. Research evidence points less often to a lack of knowledge of anatomy among doctors than to poor management and communication as the causes of medical errors.

McCarthy and Blumenthal refer to research into medical errors that shows failed communication among professionals and low-quality teamwork are prime culprits that must be addressed in changing to what they term a safety culture.

Pre-operative briefing of the entire surgical team ahead of major operations promoted patient safety in experiments done by the Kaiser Permanente healthcare group in the US. Morale improved noticeably among staff and surgical errors and near-misses were reduced.

The published research on reducing medical error is dominated by evidence that nothing works as well as communication about intentions and risks among a therapeutic team led by an individual who understands risk and discusses this with all parties who have a material interest in, and capacity to influence, the outcome for the patient. This extends to the patient and their carer.

Communication skills are vital for the future practice of safe medicine in this country to an extent that may astonish some but which is well-known beyond the halls of medicine in every industry and business that has a concern about safety and quality.

See full article by : Stephen Leeder (Australian, 26 July 2006)

Stephen Leeder is director of the Australian Health Policy Institute at the University of Sydney and co-director of the Menzies Centre for Health Policy.

[Australian DoctorsFund:Submission on Australian Medical Education]

17.07.06

GP Medical Errors

Patients are the victims of mistakes during about one in every 1000 visits to a GP, but the threat to people's safety is probably under-reported, a new study shows.

These are the key findings from a series of studies published today in the Medical Journal of Australia. The issue is devoted to general practice to coincide with Family Doctor Week.

Report co-author Dr Meredith Makeham - of the University of Sydney - said 84 GPs working in NSW took part in the survey.

These medicos submitted 418 error reports, claimed more than 490,864 consultations under Medicare, and had more than 166,500 encounters with patients during a 12-month period.

GPs had reported making one mistake for every 1000 consultation billed under Medicare and two errors for every 1000 patients seen in a 12-month period.

Dr Makeham said the results indicated that a secure website where GPs could anonymously report mistakes was a practical way to collect this information.

"[But] it is very difficult to assess the proportion of errors that would go unreported even when a reporting system such as [this] is available," she said.

"A GP may not be aware that an error has occurred.

"GPs have been found to under-report adverse drug events and so other patient safety threats may also be under-reported."

Source: Danielle Cronin, (Canberra Times, 17 July 2006)

The Threats to Australian Patient Safety (TAPS) study: incidence of reported errors in general practice Meredith A B Makeham, Michael R Kidd, Deborah C Saltman, Michael Mira, Charles Bridges-Webb, Chris Cooper and Simone Stromer — Med J Aust 2006; 185 (2): 95-98. [Full text]
 

08.07.06

State blamed for 500 patient deaths

A SENIOR doctor has likened Premier Steve Bracks and Treasurer John Brumby to funeral directors for the way they are running the hospital system. Dr Peter Lazzari yesterday said about 500 Victorians died every year because of the system's shortcomings.

"We would calculate that at least half of those deaths are preventable," Dr Lazzari said.

Of the 500 deaths, some occurred while on waiting lists and others were the result of overcrowded hospitals.

"The government spokespeople said that these people would have died anyway," Dr Lazzari told 3AW.

"That flies in the face of what medicine and hospital care are all about.

"We're there to save lives, to improve life, to relieve pain, to relieve suffering.

"I actually relate this loss of life (to) Bracks and Brumby actually functioning like funeral directors."

Dr Lazzari, who represents Victorian hospital medical staff, said the hospital funding system did not take into account pain suffered by waiting patients, the deterioration of health, and deaths.

Source: Ashley Gardiner, Herald Sun online 08.07.06.

29.06.06

Star rating system proposed for hospitals

HOSPITALS should be given star ratings based on factors such as death and infection rates, to improve performance and help patients make better informed choices, a leading health academic says.

Giving the best hospitals a five-star rating would be one option. Another would be a league table ranking the best and worst performing hospitals, according to La Trobe University dean of health sciences, Hal Swerissen.

Hospitals could be rated as above, below or at acceptable standards.

See article by Carol Nader, Health Reporter http://www.theage.com.au/news/national/star-rating-system-proposed-for-hospitals/2006/06/28/1151174268817.html

05.06.06

Hospital mishaps cost $2bn

MEDICAL mishaps and patient complications are costing Victorian hospitals about half a billion dollars each year, with the financial burden nationally estimated to be $2 billion.

A study published in The Medical Journal of Australia that examines the number and cost of "adverse events" in 45 of the state's public hospitals in 2003-04, reveals that such incidents cost the health system $460.31 million.

And it warns that the bill could be higher, if flow-on costs once a patient is discharged, and adverse events in other Victorian hospitals not included in the study, are taken into account.

"Assuming other Victorian hospitals have the same adverse events profile, the cost of adverse events for Victorian weighted inpatient activity would be about $511.457 million per annum," the report said.

"As Victoria represents about 25 per cent of national hospital expenditure, the financial toll of adverse events for Australian inpatients is estimated at about $2 billion per annum."

Of the 979,834 patient admissions included in the study, the La Trobe University researchers found almost 7 per cent — or 67,435 admissions — reported at least one adverse event.

Patients with adverse events stayed in hospital about 10 days longer, and had more than seven times the risk of in-hospital deaths than those without complications.

But the authors note, it is not possible to determine from available data to what extent the complications contributed to death.

Hospitals define adverse events as incidents in which a patient is harmed while being treated. Increased costs associated with such events include longer hospital stays, additional drugs, and further treatment in theatre.

Former professor of health policy at La Trobe University, and co-author of the study, Professor Stephen Duckett, yesterday said acting to prevent the high number of incidents could result in "enormous" savings. Previous studies indicate that between 40 and 50 per cent of adverse events are avoidable.

Professor Duckett said while he was shocked by the huge costs to hospitals, he did not believe Victoria differed from other states. "This is not only a Victorian issue, but a national issue."

The study comes after an Australian Institute of Health and Welfare report released last week showed the number of incidents of adverse events in hospitals nationwide rose by 20,000 in the past year — from 319,321 in 2003-04 to 339,551 in 2004-05.

Australian Medical Association Victorian president Dr Mark Yates yesterday said remedial action should begin with revamping hospital IT systems, boosting doctor numbers and conditions, and reducing hospital overcrowding.

Victorian Health Minister Bronwyn Pike said the Government had increased resources to deal with adverse events, and encouraged openness in reporting hospital mistakes — becoming the first state to publicly release figures on adverse events.

But Ms Pike said the HealthSMART system — including electronic prescriptions — would not be completely rolled out for another three to four years.

Source of article- http://www.theage.com.au/news/national/hospital-mishaps-cost-2bn/2006/06/04/1149359609100.htmln

[The incidence and cost of adverse events in Victorian hospitals 2003-04 Med J Aust 2006; 184 (11): 551-555.]

We are offering an obligation-free legal referral service which provides patients and their families access to lawyers with extensive experience in medical error and medical negligence, and compensation.

Our solicitors can provide you with OBLIGATION-FREE LEGAL ADVICE.

JUST COMPLETE THE CONTACT FORM, AND A SOLICITOR WILL BE IN TOUCH WITH YOU AS SOON AS POSSIBLE.

External Links:

"Make No Mistake: Medical Errors Can Be Deadly Serious" FDA Consumer magazine, September-October 2000

"Anonymity or transparency in reporting of medical error: a community-based survey in South Australia", MJA 2004; 180 (11): 577-580.

"The role of information in reducing medical error", MJA 2004; 181 (1): 27-28.