Medical errors in Victorian Public Hospitals

Public hospital errors rise 40%

By Tom Noble
October 31, 2005


VICTORIA'S public hospitals have reported a sharp rise in medical errors, including operations on the wrong body part or the wrong patient, overdoses of medication and surgical equipment left in patients after operations.

In one of 34 fatal cases last financial year, an elderly terminally ill woman died after she was given a 24-hour dose of morphine in 30 minutes.

She was being given pain relief through an intravenous drip, via an electronic pump, according to a report obtained by The Age. The mistake was made by a staff member unfamiliar with the type of pump.

The woman's death was one of 122 incidents reported to the Department of Human Services last financial year, a 43 per cent jump on the previous year's 85 reported cases and 21 deaths.

However, experts regard the reported sentinel events — infrequent, clear-cut events that can have disastrous results for patients — as only a fraction of the serious medical errors that occur in the state's hospitals.

Of the 122 events, 65 took place in metropolitan hospitals and 57 in regional or rural hospitals. However, more than three-quarters of patients are seen in metropolitan hospitals.

The events included failure to detect internal bleeding and a patient being given the wrong blood type.

Details were obtained under freedom-of-information laws.

Another death involved a man taking a blood-thinning drug who hit his head. At hospital, he was not asked for his medical history — including drugs he was taking — and was listed as non-urgent. His brain bleed went undetected until too late.

Two people died after delays in detecting internal bleeding, another two died after tubes put down their throats caused irreparable bleeding, and a woman's aorta was ruptured when surgeons accidentally dislodged a piece of brittle bone.

Other key cases included:

*The death from respiratory arrest of a mental health patient who was restrained and unattended. The case has been referred to the coroner.

*A young man who was given a colonoscopy — an exploratory tube with a camera inserted in the anus — instead of a gastroscopy, inserted in the mouth.

*A man's whose skin cancer results were not passed on for seven months, by which time he needed radical surgery.
*A man whose tonsils and adenoids were removed, when he had consented only to having his tonsils out.

*An obese woman who needed surgery to recover a surgical pack left behind after an operation.

*A blood transfusion patient given another patient's blood became restless, distressed and developed a high temperature before the mistake was discovered and the transfusion stopped. The patient survived.

*An elderly diabetic patient was given 80 units of insulin instead of eight, due to a doctor writing 8u — an abbreviation that was misread as 80. The patient suffered no complications.

Five country hospitals reported incidents in which patients were given surgery with unsterilised instruments. None was found to have been infected.

There were 25 cases of procedures on the wrong body part, including a woman who had surgery in her right ear instead of her left. Four people given anaesthetic to the wrong eye but the mistakes were discovered before surgery. Twelve cases involved X-rays or scans in the wrong place.

Eleven elderly people died after falling in hospitals or hospital-run facilities. In some cases, the falls happened despite prevention measures such as night lights, call bells and beds built low to the floor. Eighteen further cases of injury after a fall were reported.

Seven patients committed suicide in hospital grounds or while under hospital care. Three women died during or soon after childbirth. Suicide and maternal deaths are events that must be reported as sentinel events, regardless of fault.

After reporting, hospitals are required to examine why mistakes happened, change systems where necessary and share lessons with other hospitals. The program is in its fourth year.

The department would not reveal which hospitals posted the most reports, saying to do so would discourage reporting and give an inaccurate picture.

"The hospitals that report the most are the best hospitals because they … have a culture of reporting and dealing with issues. That's my feeling and that's what the literature tells us," the department's chief clinical adviser, Jenny Bartlett, said.

Ben Hart, a spokesman for Health Minister Bronwyn Pike, said learning more about mistakes meant they were less likely to be repeated.

"It is expected that the number of sentinel events reported will increase over the years as the culture of covering up mistakes changes," he said.