Australia: Fatal medication mistakes and surgery mix-ups among record number of ‘harm events’ in Victorian hospitals

Fatal medication errors killed 18 patients and four died or were seriously harmed after objects were left inside their bodies after surgery, a review into harmful events at Victorian hospitals in Australia has revealed.

The deaths are among 245 sentinel or “harm events” uncovered in the 12 months to the end of June 2023, according to a Safer Care Victoria report, up 2% on the previous year.

Four people died or were seriously harmed due to a foreign object staying in their body after surgery, including surgical sponges or dressings which can lead to infections.

Swabs are counted during procedures and the report said most errors were due to staff changing over during surgery, when a procedure involved two stages or when a dressing was modified.

Surgery or invasive procedures were performed on the wrong side of a patient’s body three times while one person underwent the wrong procedure.

Eighteen patients died due to a medication error and eight needed life-saving intervention, with prescribing issues and wrong dosages most commonly to blame.

The total number of harmful events in the year to 2023 was the highest on record since Safer Care Victoria was established in 2017.

Its chief executive, Louise McKinlay, said it was important to learn from every single event so it was not repeated.

“We’re seeing a stabilisation in the number of sentinel events being reported to us – this demonstrates an improving culture of transparency on safety risk issues and a willingness to learn from patient harm,” she said.

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Source: The Guardian, 6 September 2024