Hospital fatalities blamed on staff
By JOHN KERIN 3may99 The Australian
EIGHT in 10 incidences of needless injury or death among hospital patients have been attributed to human error.
The estimate is published in today's Medical Journal of Australia, which also warns that State and federal governments and health authorities have failed to improve hospitals enough.
A 1995 study, Quality in Australian Healthcare, indicated as many as 50,000 patients were injured and 18,000 died each year due to errors in hospitals.
The MJA publishes today a new analysis of the 1995 study, which shows 81.1 per cent of 1922 cases of temporary disability or death were the result of "human error".
More specifically, 34.6 per cent of those cases were attributed to the failure by the doctor or surgeon in "technical performance" successfullycarrying out an operation.
Another 15.8 per cent were attributed to failure to decide or act whereinformation was available, 11.8 per cent to failure to investigate or consult and 10.9 per cent to lack of care or failure to attend.
The study says of the 1182 cases identified as having high preventability, 24.7 per cent could have been avoided through better education and training, 20.9 per cent through new and better-implemented policies and 18.6 per cent through better monitoring.
Head of the analysis research team, Ross Wilson, director of quality assurance at Sydney's Royal North Shore Hospital and co-author of the 1995 study, called for the immediate adoption of electronic patient-tracking and drug-prescribing systems, and improved training and working conditions in hospitals to curb the figures.
Reader in psychology at the Clinical Risk Unit at University College in London, Charles Vincent, says in the MJA editorial that, despite the Government allocating $658 million over the next five years, "the pace of change nevertheless seems too slow, given the stark message of the original study four years ago".
"Since then, thousands more Australians have presumably been injured or died through deficiencies in the healthcare system," Dr Vincent says. "It is hoped that 1999 will see the necessary consensus for urgent action . . .achieving change on the required scale will require a specific commitment from all healthcare providers, administrators and consumers, as well as unequivocal sustained government support."
Dr Vincent says while it would be tempting to blame doctors and nurses for the errors, the reality is far more complex.
He says it could be reflected in factors such as inexperience, lack of supervision, inadequate knowledge, delay in obtaining test results, the unavailability of senior members of staff, hospital training policies and inadequate and haphazard communication systems.
Australian Consumers Association health policy officer Nicola Ballenden said the Government should be boosting funds for patient safety instead of putting $1.4 billion a year towards propping up private health insurance.
Australian Medical Association president Dr David Brand said the profession was working with State and federal health ministers to address quality and safety standards.