Mistakes causing death or serious injuries in SA hospitals on the rise

Sentinel events causing death or serious harm are on the rise in SA public hospitals, a new report has uncovered.

Catastrophic events in SA public hospitals are on the rise with seven “sentinel events” causing death or serious harm to patients, latest figures show.

They include a case where the wrong surgery was performed on a patient and a case where a person was restrained physically or mechanically with tragic consequences.

Other disasters causing death or serious harm included four cases of the wrong medication being given to patients and the suspected suicide of a patient in an acute psychiatric unit.

The seven cases in 2022-23 were up from five the previous year, and four a year earlier, while nationally there were 84 sentinel events, 13 more than a year earlier.

Interstate calamities included seven cases of surgery being performed on the wrong site of the patient — one each in NSW and WA, two in Queensland and three in Victoria.

Victoria had two cases of foreign objects accidentally being left inside patients after surgery resulting in serious harm or death.

Catastrophic events in public hospitals causing death or serious harm are on the rise nationally.

There were 51 cases nationally of patients dying or suffering serious harm after being given the wrong meds.

Fortunately, there were no cases of surgery being performed on the wrong person resulting in death, or of the discharge of an infant or child to an unauthorised person.

The seven sentinel events in SA are against a backdrop of 480,588 “separations” — a completed episode of care for an admitted patient — in SA public hospitals in 2022-23.

In 2019-20 SA had five sentinel events including two cases of foreign objects accidentally being left inside patients causing death or serious harm, and in the past has had up to 11 cases a year.

SA Health deputy chief executive, clinical systems support and improvement, Kerrie Mahon said after any sentinel event, clinical staff undertake a complex review.

“These reviews investigate the contributing factors of an event and identify improvements to prevent the event from happening again,” she said.

“Sentinel events constitute a very small proportion of all incidents reported, at approximately 0.006 per cent. This also represents a very small proportion of the hundreds of thousands of patients that SA Health doctors and nurses treat each year.

“Reflecting the positive safety culture across SA Health with high rates of reporting and low incidence of harm, 93 per cent of all medication incidents are near-miss or no-harm incidents. “Serious medications incidents, including sentinel events, constitute a very small proportion of all reported medication-related incidents and importantly, have decreased from 0.25 per cent in 2022-23 to 0.13 per cent in 2023-24.”

Between 2009-10 and 2020-21 SA Health paid out almost $130m to settle 835 compensation claims.