Medical mistakes queried
35-year-old patient went to an emergency department complaining of severe renal colic. He asked for a painkiller called hydromorphone, also known as Dilaudid, which he had previously found to be the most effective medication. Instead the doctor ordered hydromorphine — a drug eight times more powerful — because she did not realise the difference.
The bulletin said this patient did not suffer any negative long-term effects from the overdose, although it added that some other previous mix-ups involving hydromorphone have resulted in patient deaths’’. This week’s report said the reporting culture was improving, and numbers of reported events will be higher in future reports.
But other safety experts think Horvath’s suggestion that this week’s figures already represent a significant proportion of the problem is little short of ridiculous.
Steve Bolsin, associate professor of patient safety at Victoria’s Geelong Hospital, says the ‘‘ notion that 130 adverse events is the majority of the iceberg is completely erroneous. Previous work has shown that between 5 and 10 per cent of admissions have adverse events associated with them, and things may be worse in general practice. So there’s a huge need to begin to improve in these areas.’’
Bolsin points to the findings of the groundbreaking Quality in Australian Health Care Study (QAHCS), published in the MedicalJournalofAustralia 12 years ago (1995;163:458-71), which claimed that up to 16 per cent of hospitalised patients would suffer an adverse event, and that 50 per cent of these would be preventable. Of these preventable events, 10 per cent would lead to permanent disability or death.
Some doctors have been bitterly critical of the QAHCS findings, saying it was biased and found a much higher rate of adverse events than a similar US study. Had the same analysis applied in Australia as in the US, they say, the rate of adverse events reported in QAHCS would have been up to 25 per cent less.
With 4.3 million hospitalisations in public hospitals in 2004-05, the QAHCS suggests Australia’s toll of serious adverse events should be closer to 35,000 than 130. But even a 25 per cent pullback from that figure still paints a worrying picture.
A follow-up editorial in the MJA two years ago (2005;182:260-1) asked if there was any evidence that health care had become any safer in the decade since the 1995 report, and promptly answered the question itself: Unfortunately, the answer is no’’. Adverse events are also associated with significant costs. Another study in the MJA last year (2006;184:551-5), conducted in 45 major Victorian hospitals, found each adverse event contributed an extra $6826 in costs, and the total cost for all the events in the participating hospitals in 2003-04 was $460 million — over 15 per cent of direct hospital costs.
Bolsin says there are ‘‘ an incredible number of adverse events going on that are not being reported’’ through the existing channels. However, a pioneering scheme already piloted at his own hospital in Geelong could hold the answer.
For the pilot, 14 anaesthetic registrars used personal digital assistants (PDAs) fitted with special software to report adverse events to a central database, identifying them in one of four categories — events causing death, serious outcomes such as extended hospital stay or permanent harm, transient or minor harm, and ‘‘ near miss’’ adverse events that had no bad effect on the patient. Researchers combed through the notes of cases where no incidents had been reported, to check how many incidents had been missed.
The findings, reported last year in the International Journal for Quality in Health Care (2006;18(6):452-7), found an adverse incident was reported for 156, or 3.5 per cent of the 4441 anaesthetic procedures reported, nearly half (46.2 per cent) of which were near misses.
Only one incident was identified in the case notes as having been missed, giving a reporting rate via PDAs of 99.5 per cent — far higher than has been achieved anywhere else in the world.
Bolsin says PDAs can also be used to download appropriate clinical practice guidelines and other relevant information to help guide doctors, use of which he says has been proven to improve treatment outcomes.
So far, however, there has been limited enthusiasm from health bureaucrats for implementing a PDA-based system for adverse event reporting. ‘‘ If we are really serious about safety in health care, we have to start using these technologies, and we have to start using them effectively and constructively,’’ Bolsin says.