BLUN­DER BUST

Safety ex­perts say too lit­tle is be­ing done to stop pa­tients be­ing harmed or even killed by avoid­able er­rors. Health ed­i­tor Adam Cress­well re­ports

The Weekend Australian - Travel - - Health -

PA­TRI­CIA Skin­ner has ex­pe­ri­enced the sharp end of med­i­cal mis­takes. She spent 18 months with a pair of 15cm open scis­sors embed­ded in her ab­domen, af­ter doc­tors for­got to take them out at the end of an op­er­a­tion. ‘‘ It was agony . . . my hus­band would drive over a bump in the road, and I would scream,’’ re­calls Skin­ner. ‘‘ My hus­band would say, ‘ What’s the mat­ter with you?’, and I thought I had can­cer. I said to my doc­tor, ‘ I feel like I’ve been knocked to the ground and some­one’s been kick­ing me with steel-capped boots’.’’

In a way, of course, some­thing had. But un­for­tu­nately for Skin­ner, now 79, for some time med­i­cal staff re­fused to be­lieve any­thing was wrong. She had had ma­jor surgery, they told her; what did she ex­pect?

The truth was only dis­cov­ered af­ter Skin­ner her­self even­tu­ally in­sisted on an X-ray, which was per­formed at Syd­ney’s St Ge­orge Hospi­tal in Oc­to­ber 2002, 18 months af­ter surgery at the same hospi­tal to re­move bowel polyps.

‘‘ They did the X-ray twice, be­cause I don’t think they could be­lieve what they were see­ing,’’ Skin­ner says.

She went straight back to the hospi­tal, and had surgery to re­move the scis­sors the very next day. But af­ter so long inside her, the scis­sors — which in the mean­time had moved from her ab­domen to near her coc­cyx, the tail­bone at the base of the spine — had be­come par­tially over­grown by her own tis­sues. To get them out, doc­tors had to cut out a chunk of Skin­ner’s bowel as well.

What she wanted then was an ex­pla­na­tion of how it could have hap­pened, but Skin­ner and hus­band Don had lit­tle joy here ei­ther.

‘‘ They said at the time that scis­sors were ‘ too big to lose’, which was ab­so­lute non­sense,’’ Skin­ner tells Week­end Health.

‘‘ Was some­body off sick, or was some­body work­ing for hours and gOt tired? I said there must have been a rea­son, but I wasn’t al­lowed to talk to any­body. If you can un­der­stand what hap­pened, you think, ‘ OK, I can ac­cept that’. But when you don’t know, there’s noth­ing to ac­cept.’’The X-ray images and her story were re­ported around the world, and even­tu­ally Skin­ner, now 72, ac­cepted com­pen­sa­tion from the hospi­tal, the size of which is con­fi­den­tial. The hospi­tal also changed its count­ing pro­ce­dures to make sure equip­ment is prop­erly ac­counted for af­ter op­er­a­tions.

Sadly, as Aus­tralia’s first na­tional re­port on se­ri­ous mis­takes shows, Skin­ner’s ex­pe­ri­ence is far from unique, ei­ther in terms of the mis­take or the cul­ture of se­crecy and de­nial that sur­rounded it.

The re­port, pub­lished this week by the Aus­tralian In­sti­tute of Health and Wel­fare and the Aus­tralian Com­mis­sion on Safety and Qual­ity in Health Care, recorded 130 in­stances of ‘‘ sen­tinel events’’ re­ported by 759 pub­lic hos­pi­tals in 2004-05. Th­ese events fell into one of eight cat­e­gories of se­ri­ous events that were agreed by Aus­tralian Gov­ern­ments in 2004.

As The Aus­tralian re­ported this week, nearly half (41 per cent) of the 130 events were in the cat­e­gory of wrong site or wrong pa­tient — where an op­er­a­tion or test was per­formed on the wrong part of the pa­tient’s body, or on the wrong pa­tient al­to­gether.

Re­tained in­stru­ments — the cat­e­gory that Skin­ner would have fallen into — sec­ond place, ac­count­ing for 27 cases.

The fac­tors that con­trib­uted to th­ese and other in­ci­dents were var­ied: staff end­ing their shift giv­ing in­ad­e­quate brief­ings to other staff start­ing a shift, or staff act­ing when they didn’t know the full facts. For ex­am­ple, in one

took in­ci­dent a pa­tient was trans­fused wiTh blood in­tended for an­other pa­tient with an in­com­pat­i­ble blood type — a po­ten­tially fa­tal mis­take — be­cause the co-or­di­nat­ing nurse only knew of one trans­fu­sion re­quest, and when a courier de­liv­ered some blood she as­sumed — wrongly — that it was meant for that pa­tient.

Other rea­sons in­cluded staff not fol­low­ing rules or guide­lines, or not record­ing in­for­ma­tion on charts or other doc­u­ments prop­erly.

The re­port’s au­thors say the rea­sons for doc­tors and nurses not re­port­ing mis­takes in the past in­clude ‘‘ fear of lit­i­ga­tion and ad­verse pub­lic­ity’’, and ad­mit that while low, the num­bers of sen­tinel events in this week’s re­port are likely to rise in fu­ture edi­tions as doc­tors and nurses start to feel more com­fort­able about own­ing up af­ter some­thing has gone wrong.

Even so, out­go­ing com­mis­sion chief ex­ec­u­tive Diana Hor­vath re­jected sug­ges­tions the num­bers were merely the tip of the ice­berg, claim­ing they were in­stead ‘‘ a sub­stan­tial part of it’’.

But in­de­pen­dent safety ex­perts dis­agree, and it’s not as if you have to look far to find other ex­am­ples of med­i­cal mis­takes ev­ery bit as hor­ri­fy­ing as that which hap­pened to Pat Skin­ner. In a bul­letin sent to its mem­bers ear­lier this year, doc­tors’ in­sur­ance com­pany MDA Na­tional re­vealed an un­named 24-year-old pa­tient suf­fered night­mares af­ter a ‘‘ throat pack’’ — a wad of ab­sorbent gauze or dress­ing to soak up blood and other flu­ids dur­ing surgery — was left in place af­ter pro­longed oral surgery.

‘‘ The pa­tient coughed up the throat pack some hours later on the (re­cov­ery) ward,’’ the bul­letin said. ‘‘ He was very dis­tressed . . . al­though the phar­ynx was sucked out un­der di­rect vi­sion at the end of the pro­ce­dure, the blood­stained pack was not seen un­til the pa­tient coughed it up sev­eral hours post­op­er­a­tively.

‘‘ Spo­radic re­ports of this com­pli­ca­tion con­tinue to oc­cur, some­times with dis­as­trous con­se­quences for the pa­tient.’’

MDA Na­tional said mea­sures that might help avoid re­peat oc­cur­rences in­cluded la­belling pa­tients’ fore­heads if throat packs were used, and record­ing the pack on the list of items that have to be ac­counted for at the end of the pro­ce­dure.

In an­other case in the same bul­letin, a Con­tin­ued inside, page 21

Un­kind cut: Pat and Don Skin­ner with X-rays show­ing scis­sors left be­hind af­ter surgery

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