As a person who placed a singular stamp on the office of Coroner, we asked His Honour Magistrate Graeme D. Johnstone, State Coroner of Victoria, for ways to save lives. These are his dozen recommendations:
- All serious incidents involving iatrogenic injury or death be internally examined at hospital level with a view to identifying factors and implementing counter measures.
- Accurate internal investigation aimed at identification in all factors with prevention as a goal.
- Standardized internal investigation systems would be a precursor to establishing an accurate database on preventable iatrogenic death and injury for the health system.
- A system to ensure exchange of lessons learnt from incident reviews and or inquests or both.
- Developing a model incident investigation, data collection and dissemination process for all hospitals.
- Developing a standardised investigation protocol for hospitals for all serious adverse medical events [death or injury].
- Any system should also include a data collection and reporting mechanism to ensure any problems identified are disseminated throughout the hospital/medical system in a timely way.
- Establish an independent body to consolidate and co-ordinate the many different health industry and medical standards and guidelines into a definitive, objective data collection and administrative code by which all medical professionals are bound thus minimizing litigation associated with medical negligence as the only alternative.
- Negligence should be exposed, disciplined and recorded to prevent repeat offences and hard lessons learnt.
- Errors, not individuals, should be used as knowledge and shared with all hospital systems to prevent others from making the same mistakes.
- Only truly criminal cases should fear court action. Genuine apologies and honest explanation should be the norm.
- Implement a star rating system: Key Targets that hospitals must achieve for financial incentives.
Medical Error Action Group honours the outstanding contribution of His Honour Magistrate GRAEME JOHNSTONE 1945-2012, former State Coroner of Victoria, who strove to save lives.
State Coroner of Victoria His Honour Graeme Johnstone