Australia needs to reform the way we collect and use information about patient safety, to reduce the risk of more scandals and tragedies in our hospitals.
The health system is awash with data, but the information is poorly collated, not shared with patients, and often not given to the doctors and hospital managers responsible for keeping patients safe.
Hospitals boards are often blissfully ignorant of the level of safe care being provided in their own hospitals.
Grattan Institute Health Program Director and report co-author Stephen Duckett, who led an investigation for the Victorian Government after seven babies died potentially avoidable deaths at Bacchus Marsh Hospital in 2013 and 2014, says safety scandals in Australian hospitals are “depressingly frequent”.
“They stimulate special reports and an immediate flurry of action. But the tragedy is that these safety incidents occur despite reporting, governance and oversight measures that – if they were working properly – might have detected the aberrant clinical care.”
There is no public reporting of safety data about private hospitals in Australia, and private hospitals are left outside state government monitoring of hospital safety.
Australia has dozens of collections of detailed data about particular diseases or treatments – for example the Australian Genetic Heart Disease Registry, the Australian Bleeding Disorders Registry, and the National Joint Replacement Registry – but they operate independently. This means important information about an individual patient with multiple conditions – for example someone with a knee problem and heart disease – is kept in separate data sources.
To ensure hospital safety data is more useful, it must be more trustworthy, relevant and accessible. The many different data sets should be linked, and the information should be presented more clearly so doctors can act on it and patients can understand it.
More and better safety data should be collected. And it is unethical not to better use all the data already available to improve patient care.
Some registries act like “secret squirrels” – they know about safety problems but won’t share the information with any body other that the person or clinical unit that contributed the data. Hospitals managers – and patients – remain in the dark.
Clinicians and managers need to set high standards for what is acceptable in hospitals, and they need to have access to all relevant safety data so they can meet those standards.