smh.com.au
Victorian Hospital Errors: 112 Deaths, Rise in Suicides
Victoria's 2023-24 hospital error report reveals 193 sentinel events (112 deaths), including a threefold rise in suspected suicides in acute psychiatric units (six deaths), and a rise in wrong-site surgeries (three deaths) and retained objects (two life-threatening cases).
- What were the most significant causes of sentinel events resulting in death in Victorian hospitals during the 2023-24 financial year?
- In Victoria, 193 sentinel events caused 112 deaths in 2023-24. Three patients died from wrong-site surgeries, and two suffered life-threatening complications from retained foreign objects. Thirteen deaths resulted from medication errors.
- How has the number of suspected suicides in acute psychiatric settings changed year-on-year, and what actions are being taken to address this?
- The increase in suspected suicides in acute psychiatric settings (six deaths, a threefold increase) and the rise in self-harm incidents (7% to 10%) highlight critical issues within Victoria's mental health system. The rise in sentinel events involving newborns (5% to 7%) also demands attention.
- What are the potential long-term consequences of the delayed implementation of the Royal Commission's recommendations on Victoria's mental health system, and how might this impact future sentinel events?
- Safer Care Victoria will review reporting of 'category 11' cases, a majority of incidents. Hospitals with psychiatric units must audit facilities and train staff to identify deteriorating mental health. The government's delayed implementation of Royal Commission recommendations may contribute to these issues.
Cognitive Concepts
Framing Bias
The article frames the increase in sentinel events as a serious issue, highlighting the rise in suicides in psychiatric settings and the increase in incidents involving newborns. However, it also notes improvements in reporting and a decrease in overall sentinel events compared to the previous year, presenting a balanced perspective.
Bias by Omission
The article focuses primarily on the statistics of sentinel events and doesn't delve into the specific circumstances surrounding each case. While acknowledging a rise in suicides in psychiatric units, it lacks detail on contributing factors within those units. The reasons behind the increase in sentinel events involving newborns are also not explored in detail. Omission of these details limits a comprehensive understanding of the root causes.
Sustainable Development Goals
The article reports on a significant number of preventable deaths and serious harm in Victorian hospitals, including surgical errors, medication errors, and suicides in psychiatric units. These incidents directly undermine efforts to improve the health and well-being of the population. The increase in suicides in psychiatric settings is particularly alarming.