Unnecessary deaths in Australian hospitals are “depressingly frequent” despite data being available that could prevent them, according to a new report from the Grattan Institute.
Safety scandals occur despite incident reporting, governance and oversight mechanisms that should detect “aberrant clinical care”, the Strengthening safety statistics: How to make hospital safety data more useful report claims, but improved sharing of information could save lives.
Data siloes have been a preoccupation of report co-author and Grattan Institute Health Program Director Stephen Duckett since he led an investigation for the Victorian Government into the potentially avoidable deaths of seven babies at Bacchus Marsh Hospital in 2013 and 2014.
“When I had a child I cried with joy. You can’t imagine the grief of parents when their child dies, and even worse when they then subsequently discover that it was potentially avoidable,” Duckett told Healthcare IT News Australia.
His investigation found that a number of factors had contributed to the neonatal tragedies but the failure to share information allowed problems to linger unsolved.
“Some people knew some things and other people knew other things and it didn't ever all come together. There was an incident reporting system which collected a whole lot of incident reports but nothing came out of it.”
A first step in improving hospital safety in Australia is to better use the information that is already collected by putting it in the hands of people who can apply it, and the Grattan Institute report reveals where data should be more accurate, relevant, accessible and understandable. It also claims data registries need to share information more widely, capture a greater proportion of the care given, and get data back to clinicians more quickly.
“We are investing a lot of money in these systems and we could get so much more value out of them if we improved each of them. None of them are perfect but they each have their strengths,” Duckett said.
“Can we use the data we've got to identify the problem areas before they turn into the tragedies that we’ve seen?”
The stakes are high. In Victoria, 14.6 per cent of surgical deaths have been considered potentially preventable due to factors such as lack of timely involvement of senior staff, treatment delay, and failure to recognise a problem.
Strengthening safety statistics also recommends states and private hospitals share more information with clinicians to allow them to gauge how they are performing compared to their peers and ways to improve.
The report examined routine data, clinical quality registry data, death audit data, incident reporting and investigation data, patient-reported experience measures, and patient-reported outcome measures and found that the volumes of data can be staggering and unmanageable. In NSW alone, 140,000 reports on incidents of harm to patients and ‘near-misses’ are made each year.
Electronic health records are adding to the accumulation of information as hospitals adopt the systems.
“You can look at it as an opportunity, and you can look at it as more and more information being pushed out which has to be processed somehow and we haven't got our act together in processing the information we've got let alone what's going to come from the electronic health record,” Duckett said.
A solution will be to implement EHRs that operate as more than simple data depositories.
“One is what might loosely be called a dumb transformation and the other is a more intelligent transformation and so we've got to be thinking about which one we're actually aiming to do.”