17 October 2007
AUDITOR GENERAL CALLS FOR BETTER REPORTING AND MORE EFFECTIVE LEARNING
TO REDUCE INCIDENCE OF ADVERSE EVENTS IN PUBLIC HOSPITALS
Auditor General Colin Murphy has released his report into Adverse Events
in Public Hospitals. The report released in Parliament today found that
whilst the vast majority of patients in our public hospitals are treated
safely and without incident adverse events are still a significant issue
in Western Australia.
Clinical Incidents range from near misses and minor incidents which do
not affect the patient’s health or treatment to those which cause
harm and death to the patient. Those incidents which cause harm are generally
referred to as Adverse Events.
There are no indications to suggest that the incidence of adverse events
in WA is unusually high and on the basis of reported incidents, adverse
events with severe or catastrophic outcomes for patients are rare.
WA Health’s finalised incident reports show that in 2006 there
were 25 769 clinical incidents of which 15 614 were adverse events. Of
these 820 were rated as critical causing serious harm or death. The Quality
in Australian Health Care Study (1995) found that around 50% of adverse
events may be preventable.
Adverse events also consume healthcare resources. WA Health estimate
they may be costing up to $380 million a year. Reducing adverse events
could release resources to treat additional patients.
WA Health has established state wide incident reporting, but there are
deficiencies that limit the understanding of adverse events. The examination
found that under-reporting of adverse events is a significant issue, estimating
that around one-third are reported, and that there is a lack of a coordinated
approach to improving reporting.
Information from incident reports is not timely. The Auditor General
found that, as of the end of June 2007, there were 7 000 reports waiting
to be finalised, more than half of which related to incidents that happened
more than six months earlier.
The examination found that WA Health has multiple systems which capture
information on adverse events but is not systematically using all the
available information sources to build a more complete understanding of
adverse effects.
The Auditor General’s report states that WA Health has the foundations
of a coordinated approach for improving patient safety, but system wide
learning from adverse events is at an early stage. Monitoring of the implementation
of initiatives to reduce adverse events, and evaluation of the benefits
realised, has been limited.
The Auditor General has recognised that hospitals manage and respond
to individual adverse events, and found localised examples of successful
change. However WA Health needs to ensure that the examples of good practice
and improvement are transferred across the whole system.
Whilst understanding that the demands on our public hospitals are increasing,
the Auditor General believes that: “WA Health needs to balance its
focus on delivering services in the face of increasing demand with a stronger
focus on doing no harm.” He has made a number of recommendations
to achieve this including a call for:
- Increased reporting with improved timeliness of data
- Better utilisation of all available data sources
- The setting of system wide priorities to allow the health system
to target efforts to where the greatest benefits can be realised
- Increased sharing of information between hospitals and across the
system
- A coordinated program to monitor initiatives and evaluate progress.
Ends/
Link to Auditor General's
Overview
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