Scope of Our Hospital Data
Our research so far has been interesting as to what patterns have emerged just by compiling information on approximately 224 hospitals. For a 2004 report we studied 2,781 hospital and out-of-hospital deaths associated with adverse events.
To arrive at what we formed the view to be an “adverse event” was based upon the inconsistencies and discrepancies in documentation studied, as listed below, made available to us by families nationally over a 5½ year period. We also took into account what families were told by hospitals, clinicians and government area health networks. It should be noted however, that just because a family contacts Medical Error Action Group for help, it is not automatically deemed that an adverse event has occurred.
During the course of our research, we noted the following:
- Low number of medical AEs recorded by the Australian Bureau of Statistics.
- High number of reportable deaths that had not been reported to the Coroner.
- Routine inadequate and inaccurately completed death certificates.
- Routine incomplete medical record documentation.
- Vast amounts of missing hospital medical records.
- Disappearance and tampering of medical records.
- Missing consent for medical procedure/treatment and anaesthetic forms.
- Undated and unwitnessed consent for medical procedure/treatment forms.
- ICD coding and DRG discrepancies on medical records.
- Unavailability of clinicians to make depositions to Coroners.
- Routine obstruction and poor complaint handling by hospitals.
Documentation looked at:
- Hospital medical records.
- Autopsy / post-mortem examination reports.
- Death certificates.
- Police Brief to Coroner.
- Coroner' Inquest transcripts.
- Coroners’ findings.
- ICD coding.
Time, day, month errors mostly occur:
- Early morning during shift changeover is most common time of death.
- Wednesday is the error-prone day for adverse events resulting in death.
- September is the predominant month for adverse events resulting in death.
Time of death frequency could point to:
- Patient neglect overnight.
- Inadequate staffing levels overnight.
- Too much emphasis on change of shift hand-over and not on patient needs.
- Human body at its lowest ebb during early hours of morning when ill.
We have brought this to the attention of a number of Coroners to see if there is any reason.
As displayed in the tables below, it appears that there can be no link between interns running hospitals at weekends and error-prone days. There further appears to be no link with the intake of interns causing the majority of errors either, presuming they come into public hospitals in January and February from medical school. However, we observed interns running Emergency Departments to be a major hazard for patients.
Allowing for the coldest months for people to be the sickest, September and June can be chilly in the southern states, but August, being the coldest month, is puzzlingly low frequency in our findings. September points to school holidays and football finals. Apart from August, May and October, the figures fall relatively evenly.
| Days of Week | No. of Deaths |
|---|---|
| 1. Wednesday | 765 |
| 2. Monday | 387 |
| 3. Thursday | 351 |
| 4. Friday | 342 |
| 5. Tuesday | 324 |
| 6. Saturday | 306 (equal with Sunday) |
| 7. Sunday | 306 (equal with Saturday) |
| TOTAL: | 2,781 |
| Months of Year | No. of Deaths |
|---|---|
| 1. September | 290 |
| 2. June | 271 |
| 3. March | 266 |
| 4. July | 262 |
| 5. November | 253 |
| 6. February | 248 |
| 7. December | 238 |
| 8. January | 217 |
| 9. April | 211 |
| 10. August | 180 |
| 11. May | 176 |
| 12. October | 169 |
| TOTAL: | 2,781 |