Call for voluntary error reporting

Patient deaths or ‘‘near misses'' caused by serious mistakes by health professionals should not just be reported in hospitals but in the primary health sector as well, Balclutha doctor Branko Sijnja says. 

Reporting such events was important to help prevent similar mistakes recurring, he told fellow members of a joint Otago and Southland district health board committee in Invercargill yesterday.

‘‘I'm thinking of things like, from time to time, we get calls back from pharmacists saying we have made an error in our writing [on pharmaceutical scripts].''

And GPs sometimes wrote down the wrong drug or put down incorrect dosages for drugs on patient scripts, Dr Sijnja said.

‘‘I do wonder whether setting up through primary health organisations some voluntary reporting of these sort of events could be helpful.

‘‘It is the near misses that are not picked up. I think there is probably some very significant ones out there.''

Community and public health advisory committee chairman Errol Millar said the health industry could learn much from reporting of accidents and potential accidents in the aviation and marine industries.

Otago and Southland health boards chief executive Brian Rousseau said the issue of reporting sentinel and serious events in primary health care would be discussed by the Ministry of Health's quality improvement committee. The committee released information about events at all 21 district health boards around the country last month.

A sentinel event is one which results in an unanticipated death or major permanent loss of function unrelated to the natural course of the patient's condition. A serious event has the potential to result in death or major permanent loss of function not related to patient's condition.

- Pharmaceuticals: Whether demand for pharmaceuticals in Otago and Southland was growing faster than the level of available funding was debated by committee members and health board staff.

Board member Peter Barron said an initiative to increase the effectiveness of community pharmaceutical usage appeared to be making little progress.

Mr Rousseau said the slow progress had been a source of great frustration. It was important to engage prescribers, dispensers and users of pharmaceuticals and to get those three areas working together, he said.

- PHOs: The need to involve nongovernment health care providers in primary health organisations was debated. Board member Kaye Crowther said primary health care involved an ‘‘awful lot more'' than just general practice.

‘‘There are some non-government organisations that actually do feel like they are out on a limb.''

Dr Sijnja said: ‘‘We need to take the next step. I think it is time to get the wider primary health sector involved in primary health organisations.''

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