Sunday, July 22, 2007

Dangerous public hospital negligence in Australia

Safety experts say too little is being done to stop patients being harmed or even killed by avoidable errors in Australian public hospitals

PATRICIA Skinner has experienced the sharp end of medical mistakes. She spent 18 months with a pair of 15cm scissors in her abdomen. Why? Because doctors forgot to take them out at the end of an operation. [What happened to the before-and-after count that should have been routine procedure?] "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 [A notorious 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 - took 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 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 post-operatively. "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 35-year-old patient went to an emergency department complaining of severe renal colic. He asked for a painkiller called hydromorphone, also known as Dilaudid, which he had previously found to be the most effective medication. Instead the doctor ordered hydromorphine - a drug eight times more powerful - because she did not realise the difference. The bulletin said this patient did not suffer any negative long-term effects from the overdose, although it added that some other previous mix-ups involving hydromorphone "have resulted in patient deaths''.

This week's report said the reporting culture was improving, and numbers of reported events will be higher in future reports. But other safety experts think Horvath's suggestion that this week's figures already represent a significant proportion of the problem is little short of ridiculous. Steve Bolsin, associate professor of patient safety at Victoria's Geelong Hospital, says the "notion that 130 adverse events is the majority of the iceberg is completely erroneous. Previous work has shown that between 5 and 10 per cent of admissions have adverse events associated with them, and things may be worse in general practice. So there's a huge need to begin to improve in these areas.''

Bolsin points to the findings of the groundbreaking Quality in Australian Health Care Study (QAHCS), published in the Medical Journal of Australia 12 years ago (1995;163:458-71), which claimed that up to 16 per cent of hospitalised patients would suffer an adverse event, and that 50 per cent of these would be preventable. Of these preventable events, 10 per cent would lead to permanent disability or death.

Some doctors have been bitterly critical of the QAHCS findings, saying it was biased and found a much higher rate of adverse events than a similar US study. Had the same analysis applied in Australia as in the US, they say, the rate of adverse events reported in QAHCS would have been up to 25 per cent less. With 4.3 million hospitalisations in public hospitals in 2004-05, the QAHCS suggests Australia's toll of serious adverse events should be closer to 35,000 than 130. But even a 25 per cent pullback from that figure still paints a worrying picture.

A follow-up editorial in the MJA two years ago (2005;182:260-1) asked if there was any evidence that health care had become any safer in the decade since the 1995 report, and promptly answered the question itself: "Unfortunately, the answer is no''.

Adverse events are also associated with significant costs. Another study in the MJA last year (2006;184:551-5), conducted in 45 major Victorian hospitals, found each adverse event contributed an extra $6826 in costs, and the total cost for all the events in the participating hospitals in 2003-04 was $460 million - over 15 per cent of direct hospital costs.

Bolsin says there are "an incredible number of adverse events going on that are not being reported'' through the existing channels. However, a pioneering scheme already piloted at his own hospital in Geelong could hold the answer. For the pilot, 14 anaesthetic registrars used personal digital assistants (PDAs) fitted with special software to report adverse events to a central database, identifying them in one of four categories - events causing death, serious outcomes such as extended hospital stay or permanent harm, transient or minor harm, and "near miss'' adverse events that had no bad effect on the patient. Researchers combed through the notes of cases where no incidents had been reported, to check how many incidents had been missed.

The findings, reported last year in the International Journal for Quality in Health Care (2006;18(6):452-7), found an adverse incident was reported for 156, or 3.5 per cent of the 4441 anaesthetic procedures reported, nearly half (46.2 per cent) of which were near misses. Only one incident was identified in the case notes as having been missed, giving a reporting rate via PDAs of 99.5 per cent - far higher than has been achieved anywhere else in the world. Bolsin says PDAs can also be used to download appropriate clinical practice guidelines and other relevant information to help guide doctors, use of which he says has been proven to improve treatment outcomes.

So far, however, there has been limited enthusiasm from health bureaucrats for implementing a PDA-based system for adverse event reporting. "If we are really serious about safety in health care, we have to start using these technologies, and we have to start using them effectively and constructively,'' Bolsin says.


Up against the warming zealots

Martin Durkin says his British documentary rejecting the idea of human-caused global warming has survived last week's roasting by Australia's public broadcaster

WHEN I agreed to make The Great Global Warming Swindle, I was warned a middle-class fatwa would be placed on my head. So I wasn't shocked that the film was attacked on the same night it was broadcast on ABC television last week, although I was impressed at the vehemence of the attack. I was more surprised, and delighted, by the response of the Australian public.

The ABC studio assault, led by Tony Jones, was so vitriolic it appears to have backfired. We have been inundated with messages of support, and the ABC, I am told, has been flooded with complaints. I have been trying to understand why.

First, the ferocity of the attack, I think, revealed the intolerance and defensiveness of the global warming camp. Why were Jones and co expending such energy and resources attacking one documentary? We are told the global warming theory is robust. They say you'd have to be off your chump to disagree. We have been assured for years, in countless news broadcasts and column inches, that it's definitely true. So why bother to stamp so aggressively on the one foolish documentary-maker - who clearly must be as mad as a snake - who steps out of line? I think viewers may also have wondered (reasonably) why the theory of global warming has not been subjected to this barrage of critical scrutiny by the media. After all, it's the theory of global warming, not my foolish little film, that is turning public and corporate policy on its head.

The apparent unwillingness of Jones and others at the ABC to give airtime to a counterargument, the tactics used to minimise the ostensible damage done by the film, the evident animosity towards those who questioned global warming: all of this served to give viewers a glimpse of what it was like for scientists who dared to disagree with the hallowed doctrine.

Why are the global warmers so zealous? After a year of arguing with people about this, I am convinced that it's because global warming is first and foremost a political theory. It is an expression of a whole middle-class political world view. This view is summed up in the oft-repeated phrase "we consume too much". I have also come to the conclusion that this is code for "they consume too much". People who believe it tend also to think that exotic foreign places are being ruined because vulgar oiks can afford to go there in significant numbers, they hate plastic toys from factories and prefer wooden ones from craftsmen, and so on.

All this backward-looking bigotry has found perfect expression in the idea of man-made climate disaster. It has cohered a bunch of disparate reactionary prejudices (anti-car, anti-supermarkets, anti-globalisation) into a single unquestionable truth and cause. So when you have a dig at global warming, you commit a grievous breach of social etiquette. Among the chattering classes you're a leper.

But why are the supporters of global warming so defensive? After all, the middle classes are usually confident, bordering on smug. As I found when I examined the basic data, they have plenty to be defensive about. Billions of dollars of public money have been thrown at global warming, yet the hypothesis is crumbling around their ears.

To the utter dismay of the global warming lobby, the world does not appear to be getting warmer. According to their own figures (from the UN-linked Intergovernmental Panel on Climate Change), the temperature has been static or slightly declining since 1998. The satellite data confirms this. This is clearly awkward. The least one should expect of global warming is that the Earth should be getting warmer.

Then there's the ice-core data, the jewel in the crown of global warming theory. It shows there's a connection between carbon dioxide and temperature: see Al Gore's movie. But what Gore forgets to mention is that the connection is the wrong way around; temperature leads, CO2 follows.

Then there's the precious "hockey stick". This was the famous graph that purported to show global temperature flat-lining for 1000 years, then rising during the 19th and 20th centuries. It magicked away the Medieval warm period and made the recent warming look alarming, instead of just part of the general toing and froing of the Earth's climate. But then researchers took the computer program that produced the hockey stick graph and fed it random data. Bingo, out popped hockey stick shapes every time. (See the report by Edward Wegman of George Mason University in Virginia and others.) In a humiliating climb down, the IPCC has had to drop the hockey stick from its reports, though it can still be seen in Gore's movie.

And finally, there are those pesky satellites. If greenhouse gases were the cause of warming, then the rate of warming should have been greater, higher up in the Earth's atmosphere (the bit known as the troposphere). But all the satellite and balloon data says the exact opposite. In other words, the best observational data we have flatly contradicts the whole bally idea of man-made climate change.

They concede that CO2 cannot have caused the warming at the beginning of the 20th century, which was greater and steeper than the recent warming. They can't explain the cooling from 1940 to the mid-'70s. What are they left with? Some mild warming in the '80s and '90s that does not appear to have been caused by greenhouse gases. The whole damned theory is in tatters. No wonder they're defensive.

The man-made global warming parade, on one level, has been a phenomenal success. There isn't a political party or important public body or large corporation that doesn't feel compelled to pay lip service. There are scientists and journalists (a surprising number) who have built careers championing the cause. There's more money going into global warming research than there is chasing a cure for cancer. Many important people and institutions have staked their reputations on it. There's a lot riding on this theory. And it has bugger-all to do with sea levels. That is why the warmers greeted my film with red glowing eyes.

Last week on the ABC they closed ranks. They were not interested in a genuine debate. They wanted to shut it down. And thousands of wonderful, sane, bolshie Australian viewers saw right through it. God bless Australia. The DVD will be out soon.


Serious loss of mathematics skills in Australia

AUSTRALIA is losing its mathematical skills as school courses are hijacked by fads and divorced from modern mathematics as practised in industry and business. At a time when economic growth is underpinned by jobs in maths-related fields, the Australian Mathematical Sciences Institute says the teaching and learning of maths in schools and universities is in serious trouble and suffering from a lack of input from mathematicians. Not only is the number of students taking maths continually falling, especially at an advanced level, but even students studying related fields such as engineering and science are taking fewer maths courses.

In a submission to a numeracy review being undertaken by federal, state and territory governments under the auspices of the Council of Australian Governments, AMSI is critical of the review for its ignorance of modern maths and its application in industry and business, and for failing to include mathematicians in the process. "Mathematicians and statisticians have had few opportunities to be involved in school mathematics for a number of years," says AMSI, representing 30 universities and mathematical organisations. "As a result, serious misconceptions concerning modern mathematics are arising ... particularly concerning the role of foundation or 'pure' mathematics."

AMSI says that in the absence of input from experts and users of mathematical sciences across the trades and professions, school curriculums tend not to reflect pertinent mathematical content and have become the victim of fads. Mathematics has also "lost coherence and many of its successful teachers". "We are deeply concerned by the failure of the background (review) paper to address specific content, the apparent lack of knowledge of modern mathematical sciences, the inability to give examples of good practice (at) high-achieving schools and failure to address Australian curriculum expectations compared to those of other nations," the submission notes.

It says school curriculums tended to reflect the belief that pure maths courses were only required for highly specialised areas, when pure maths was a vital element of many new applications in various fields, such as climate change, as well as providing the fundamental understanding required to apply mathematical concepts.


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