Patient seriously harmed after equipment fails during heart surgery

A patient has been seriously harmed after an equipment malfunction during recent heart surgery at a Melbourne hospital.

The equipment fault occurred at the Austin in Heidelberg when the patient was on cardiopulmonary bypass, which means a machine was taking over their heart and lung function.

The Austin Hospital in Heidelberg.Credit: Eddie Jim

The incident has been declared a sentinel event – often defined as a preventable adverse safety event that has resulted in serious harm to a patient – and reported to Safer Care Victoria, an office of the state’s health department that focuses on healthcare safety.

The patient is now in a serious but stable condition, Austin Health said.

“We have identified the device involved and have removed it from clinical use,” a spokesperson said.

A heart-lung machine used in cardiac surgery.Credit: iStock

“This device will not be used for future surgeries at Austin Health. Investigations so far have not identified human error as a contributing factor to this event.

“The investigation has now been handed over to Safer Care Victoria. Our internal investigations have already been conducted and completed.”

The incident caused a brief pause in elective cardiac surgery at the Austin Hospital, though there were no delays to operations as procedures were accommodated elsewhere. “Emergency cardiac surgery proceeded as normal,” the health service said.

Safer Care Victoria confirmed it had been notified of an “adverse patient safety event” that occurred at the Austin Hospital.

“The event is being reviewed as per the required process and it would not be appropriate to comment further while that review is under way,” a spokesperson said.

From July 2021 to June 2022, 151 people died because of preventable errors in Victorian hospitals, according to data obtained by The Age via freedom of information laws.

Another 24 had their life expectancy reduced because of an adverse event caused by system and process deficiencies, 22 suffered permanent or long-term loss of function and eight experienced long-term physical harm.

The state government is yet to publish its more recent sentinel event data from the 2022-23 financial year.

The last time Safer Care Victoria published information on sentinel events caused by medical devices or equipment was for the 2020-2021 financial year, when there were two such events caused by equipment issues – down from five the preceding year.

The most recent sentinel event annual report, for the financial year ending June 2022, provides much fewer details than in the past, reduced from 63 pages in the preceding year to 17 pages, despite taking months longer than usual to publish.

Information that was included previously such as the number of sentinel events that related to mental health or residential aged care, and the number of suspected suicides among patients in psychiatric units, was not included.

And as hundreds of Victorians died after catching COVID-19 in hospital while receiving care for other conditions, Safer Care Victoria also ditched a requirement for these deaths to be classified as sentinel events. Before the pandemic, only a handful of Victorians died each year in hospitals of healthcare-acquired infections, according to sentinel event reports.

Safer Care Victoria defines a sentinel event as“when something goes wrong with a patient’s care that causes them serious harm or death that could have been prevented”.

Serious harm means that the patient either needed life-saving surgical or medical care that they wouldn’t have needed if their care had gone well, won’t live as long as they would have otherwise, or has experienced long-term harm or lost the ability to do things.

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