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