In 2013-14, just under 2000 people died who had surgery. Most were elderly with pre-existing health conditions.Hundreds of patient deaths in Victorian hospitals over the last seven years could have been avoided, an audit has revealed.
Some of the problems that may have contributed to the deaths include ambulance delays to transfer patients to a more appropriate hospital, a shortage of intensive care unit beds to care for them after surgery, and poor decision making by staff.
The most recent Victorian Audit of Surgical Mortality has found that about 0.3 per cent of people having surgery in public and private hospitals died either during the procedure or within 30 days of leaving hospital after it.
In 2013-14, this equated to 1,924 patients out of the 663,768 who had surgery. The deaths were primarily among elderly patients with an average age of 79 and most had pre-existing health conditions.
Clinical director of the audit Barry Beiles said while the death rate had dropped from 0.4 per cent in 2007, the most recent review identified a range of areas for improvement.
When surgeons looked closely at 4,905 deaths between 2007 and 2014, he said they found nine per cent or 462 involved “areas of concern”, and six per cent or 288 involved “adverse events”.
An adverse event is an unintended injury that was caused by the medical management of the patient such as a blood vessel that was cut when it should not be.
In 20 per cent or 997 cases, the clinical management issue may have contributed to the death and in five per cent or 248 cases, it probably contributed to their death.
The audit found that six per cent or 292 of the clinical management issues identified were definitely preventable; 13 per cent or 641 were probably preventable; and one per cent or 72 were definitely not preventable.
Mr Beiles, a vascular surgeon, said while death rates and clinical management issues had decreased over the course of the seven-year audit, and no surgeons stood out as bad performers, the report highlighted some ongoing problems.
These included delayed diagnosis for patients; delayed ambulance transfers to more appropriate hospitals particularly for patients in rural areas; communication breakdowns between health professionals and a shortage of intensive care beds when patients need critical care.
Furthermore, in some cases, not enough was being done to prevent deep vein thromboembolism (DVT) for patients before surgery.
Mr Beiles said the Royal Australasian College of Surgeons was working with Victorian surgeons, the department of health and hospitals to address these issues.
“I think people should be reassured that an extremely low percentage of people having an operation in Victoria will actually die,” he said.
Mr Beiles said assessments of deaths that identified clinical management issues were sent back to treating surgeons so they could learn and improve their care.
This story Administrator ready to work first appeared on Nanjing Night Net.