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 Tuesday, May 10, 2005

Australian Hospitals: Error-Prone and FAILING Their Patients

  9 May 2005

Read here full article by Clara Pirani in The Australian

by Clara Pirani

Edited article

Australian hospitals are failing to implement simple procedures to avoid repeating medication errors that have killed and injured hundreds of patients.

Almost 900 patients have been the victims of medication errors involving anaesthesia during the past 10 years, ranging from anaesthetists injecting the wrong drug or injecting a drug into the wrong part of the body.

About 45 cases have resulted in death or caused a serious reaction.

In 1995, a patient safety report stunned the medical community by claiming that every year 18,000 Australians died unnecessarily from "adverse events" - complications caused by the healthcare they received in hospital.

Bill Runciman, head of Royal Adelaide Hospital's department of anaesthesia and intensive care, warned that the figure could be higher, but said 75 per cent of the errors could be prevented if Australian hospitals introduced a standardised method for administering anaesthesia. He said:

"There are a whole bunch of committees and taskforces that have discussions and make recommendations, but at the end of the day, governments DON'T appear to be terribly enthusiastic about introducing standardised measures to make the system safer.

In the past 10 years some problems might have improved but they may have been replaced by new problems. We literally don't know.

There are about 30 stages in the process of giving an intravenous injection, and when this is being done in complex cases, say with cardiac patients, the anaesthetist might have 10 or 12 of these syringes drawn up.

Simple things like having a tray where you lay the syringes out in the order that you are going to use them would help.

That whole series of errors in putting the wrong drug in the wrong syringe can be completely avoided."

Professor Runciman said simple changes to the way anaesthesia was administered could prevent many errors.

He said errors that involved the wrong drug being placed in the syringe often occurred in the operating theatre, where medical staff worked under great pressure and time constraints.

Instead, hospitals should stock syringes that were already filled with the correct medication, labelled and colour-coded at a pharmacy.

Ross Wilson, chairman of the National Medication Safety Taskforce at the Australian Council for Safety and Quality in Health Care, said FEW hospitals were conducting routine checks to make sure patients received the right medication and dosage.

Dr Wilson said there was insufficient monitoring of medication errors in Australia, but he argued that mandatory reporting was unnecessary. He added:

"There are so many errors that we really couldn't actually manage all of those, but we really have a responsibility to detect and respond to the errors that harm patients.

We need to be detecting them with a combination of a voluntary reporting system and some form of medical record audit or medication chart review on a routine basis.

But in Australia routine monitoring is the exception rather than the rule."

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