Med­i­cal mis­takes queried

The Weekend Australian - Travel - - Health - From Health cover

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.

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