Deadly hospital slip-ups
Warning of more harm if health system stresses build
DOZENS of patients at Barwon Health were put at risk of significant harm in avoidable incidents, a report has found.
The organisation’s Quality Account report for 2017/18 identified 70 such incidents that could have been prevented.
Six resulted in permanent harm or death to a patient. Five of those had “severe” outcomes and one was classified as “moderate”.
It is unclear whether any- one died as a result, with Barwon Health refusing to disclose further information about the cases.
A spokeswoman for the health service said it was common practice for hospitals to withhold information on preventable cases that resulted in permanent harm or death — otherwise known as sentinel events.
“Sentinel events data is deidentified, and the purpose of the data is to encourage health services to share and investigate incidents to improve care and safety across the whole health system,” the spokeswoman said. “Barwon Health has a robust clinical risk program working throughout the health service to encourage reporting and develop system improvements in order to maintain excellent hospital quality and safety standards.”
According to the organisation’s report, all sentinel events have undergone “extensive” review and culminated in risk reduction action plans.
Each review has been submitted to Safer Care Victoria — a state government body — and tabled at Barwon Health executive meetings to “ensure the actions are completed and lessons are learnt”, the report said.
The figures prompted a legal expert to warn of challenges facing the health service amid a population boom.
Tom Ballantyne, a principal lawyer at Maurice Blackburn specialising in medical negligence, said Barwon Health needed to ensure its processes and resources were growing to meet an increasing demand.
“The reality is six sentinel events in a year; even the health service would say it is obviously six too many. No one wants these sorts of outcomes,” he said.
“We often see that health services away from Melbourne’s CBD can be placed under significant stress.
“If health services aren’t able to keep up with demand and are placed under greater strain and stress, then we will see an even greater increase in adverse outcomes.”
The number of sentinel events reported at Barwon Health in 2017-18 coincided with a sharp increase across the state. A total of 122 sentinel events were recorded in Victoria last financial year — up 69 per cent on 2016-17.
Mr Ballantyne said while it was impossible to know if Barwon Health was disproportionately represented in the sentinel data, it was important to understand the “devastating” impact avoidable mistakes and complications could have.
“We are talking about deaths, we are talking about permanent ongoing injuries, and it’s crucial that any health service — private or public — does everything they can to minimise that,” he said.