The ACT Coroner is investigating the death of a Canberra Hospital patient who died after an operation was performed on the wrong body part.
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Internal reports obtained by The Canberra Times under freedom of information laws reveal that the hospital apologised to the patient's family after surgeons operated on the wrong hip.
The final report into what the hospital classed as a ''catastrophic incident'' - the worst category that can be given to medical errors at the hospital - said the operation was subsequently done on the correct side.
But the report shows the woman later died.
A Health Directorate spokeswoman yesterday said the coroner was still trying to work out if the patient died because of the botched operation or because of other health problems she had been diagnosed with.
The Canberra Times can reveal the incident is among a number of serious mistakes made at Canberra Hospital since the middle of last year.
Other incidents include:
- one patient being given five times the dose of a chemotherapy drug.
- a urine duct being incorrectly cut during an operation.
- a delayed diagnosis of a severe spinal injury.
- a child being given a paracetamol overdose. In relation to the 'catastrophic'' hip surgery, the internal documents show the hospital described the outcome as ''extreme'' and has grouped the incident under a category of catastrophic procedures as ''involving the wrong body part resulting in death or major permanent loss of function''. Details of the incident were sent to the ACT Insurance Authority. The Health Directorate spokeswoman said $2.6 million had been paid out in medical negligence claims at Canberra Hospital in the past 16 months, but it was likely these compensation payments were made for mistakes in previous years. The directorate spokeswoman said health care was a complex, human-based system and ''at times, things can go wrong''. ''We recognise the hardship for the patients, their families, and their friends in relation to these incidents and have extended full support, care and assistance to all involved and will continue to do so. ''Any adverse event is a concern ... we are fortunate in the ACT that adverse events are not common. ''ACT Government Health Directorate performed 17,905 surgeries in 2010-11 financial year, and the number of adverse events you refer to represent a very small percentage of cases.'' The spokeswoman said recent improvements at the hospital included new checklists, a redesigned program for improving clinical care delivery and access, a new complaints system and a newly formed quality committee. The internal reports show an urgent review of paracetamol guidelines across Canberra Hospital was sparked when the child patient overdosed on intravenous drip paracetamol. Staff involved were later told the correct dose of paracetamol per kilogram for a child. Again the hospital's medico-legal coordinator was asked to refer the incident to the ACT Insurance Authority. The ''high-risk'' incident was described as a ''near miss'' that could have been worse if not detected. Another ''near miss'' happened when a patient's treatment was delayed after they were given five times the dose of a chemotherapy drug, a mistake that also resulted in ''low blood counts''. The patient was given 3200mg of cytarabine instead of 640mg, but the papers suggest it was not the hospital's fault. ''[The] pharmacy are implementing a new electronic prescribing system that should decrease the occurrence of manufacturing errors,'' the final report said. In the antenatal ward, one woman had her ureter - a urine duct between the kidney and bladder - mistakenly cut. It appears from the documents that staff at the hospital used the incident to highlight the lack of an interventional radiologist, a specialist who uses a range of technology to treat patients non-surgically. The documents also said one patient suffered major and permanent loss of function after a delayed diagnosis of a severe spinal injury. The patient was transferred to Royal North Shore Hospital in Sydney, had urgent decompressive surgery and was put in an intensive care unit. He was discharged from hospital walking and the documents said he had ''ongoing neurogenic bladder and bowel issues'' being followed up in the community. In the final report about the delayed spinal injury diagnosis under ''staff factors'', the words ''inadequate staffing'', ''inadequate training'', ''excessive hours'' and ''lack of medical consultant supervision'' were written. Under the heading of ''equipment'', the word ''failure'' was typed. Further down, under the ''Procedures and Guidelines'' heading, were typed the words ''failure to follow procedures and guidelines''.
