Public hospital horror stories will always arise. Hospitals
operate in life and death zones in the midst of medical
complexity and human interaction. There is a lot that can go
It is encouraging, therefore, to learn this week reported
instances of harm in Southern District Health Board hospitals
have fallen by 25%. The 2011-12 "serious and sentinel" report
showed Southern had 30 events, 10 fewer than the previous
There were six deaths, although these were not necessarily
because of the reported incident.
Southern's patient services medical director Dick Bunton
claims the fall is not because of a reluctance to report
incidents but rather because enhancements are taking place.
Lessons are being learned from past errors, and procedures
are improving. People could infer from the drop in cases that
public hospitals in the South were becoming safer. Hopefully,
Mr Bunton's comments reflect what is happening and are much
more than just positive spin.
Hopefully, too, improvements continue.
The key, it seems, to effective reporting and continuous
progress is banishing a blame-and-shame culture. If staff are
fearful they will not raise issues. If mistakes are buried
and backs covered, problems will remain hidden and solutions
cannot be found.
Inevitably, however, this is easier said than carried out in
practice. It is always difficult to admit errors for reasons
of pride, guilt, shame, career advancement and sometimes
culpability consequences. Yet, that has to be done.
Staff have to know it is their duty to report when things go
And supervisors and the hospital hierarchy have to deal with
these situations with tact and skill.
Running in parallel must be "robust" reporting systems. Those
who might be reluctant to come forward need to feel they have
little choice. They know that someone else will be reporting
some aspect of the incident so they might as well be up
Complicating matters, too, is the fact in any organisation -
let alone one with thousands of employees - there will always
be staff who, for various reasons, are not up to the job.
They are likely, not surprisingly, to be particularly
defensive about adverse events.
And there will be a few occasions where sympathy and
understanding towards staff is no longer appropriate.
Overall, however, Mr Bunton said the combination of a medical
culture that was less likely to hide mistakes and the
"robust" reporting systems had led to improvements. Rather
than fear criticism, incidents were much more likely to be
reported. The six years of reports and their follow up had
helped change attitudes.
All involved realise, as they should, that every incident is
one that should not have happened, that every instance
affects the lives of individuals, that - as Health Quality
and Safety Commission chairman Prof Alan Merry has said -
every event has "a name, a face, and a family", and that
should never be overlooked.
In Southern's case, the unnecessary mastectomy, the death of
a patient after CPR was not administered because of an
incorrect assumption about a "not for resuscitation" order,
the tumour identified as an incidental scan finding and not
followed up and the other incidents, indeed, are horror
stories for those concerned.
Of course, human error will never be entirely eliminated,
whatever the systems and procedures and however much everyone
is doing their best. What can be achieved, nevertheless, is
progress towards the ideal of eliminating all such events.
Those who introduced the reporting systems can be pleased at
the progress. The next step, the commission says, is to
increase the range of organisations subject to future
reports, perhaps to include private hospitals (where it is
good to see Mercy Hospital voluntarily leading the way),
hospices, ambulance and care agencies.
An additional challenge will be to combat the fear of bad
publicity in private and/or competitive fields. It is easier
for what some might see as "dirty linen" to be aired in
public with a public body rather than a private provider.
Given, though, the heartening success of the events reporting
system for public hospitals, efforts should be made to extend
its reach. Every "horror" story that can be avoided is one
less instance of pain and heartbreak.