You go to hospital to get better - but unfortunately 750 people last year didn’t get better, indeed the result of their hospital experience was death and these deaths were “potentially avoidable”.

A further (approximately) 5,000 people “suffered preventable, serious harm ” - from about 600,000 hospital admissions per year. In percentage terms that’s 0.125% for avoidable death and 0.833% for avoidable serious harm.

It always seems cold and callous to express the loss in dollar terms (PDF 32kb) but it does give a common reference that is sometimes easier to appreciate. The last sum agreed in late 1990s was $2.5m per death (a revised estimate of $4m has yet to be agreed). Working with the $2.5m figure that amounts to $1.875bn of avoidable loss annually.

It’s not a new problem - “…what has been in health services for as long as we know.” It’s a classic case of repetitive failure. Worse - there is an expectation of “the inevitability of harm”.

So what is going to be done about this $1.8bn WOMBAT?

Canterbury is conducting a “safe-patient journey” initiative to streamline patient movement at the hospital.

I’d hope that this initiative is a result of a systematic analysis of the root causes of failure and addresses those causes not just the symptoms.

This problem is best addressed by analysing each instance and the root cause of that particular instance - the causes of that instance alone and ensuring that one instance could never happen again. And then do the next one, and the next one and the next one. Each failure is an opportunity to learn and prevent.

Avoidable harm is not inevitable.

This entry was posted on Saturday, May 5th, 2007 at 2:38 pm and is filed under Repetitive Failure, WOMBATS. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.