Surgeons shunning checklists on safety

Surgeons shunning checklists on safety

Canberra Hospital surgeons failed to complete vital pre-surgery safety documents in most cases examined by an internal audit last year, ACT Health documents reveal.

And the papers show some Canberra Hospital surgeons were correctly filling in surgical safety checklists in just 4 per cent of the operations they performed in April 2011, the month before an elderly Yass woman died after a catastrophic surgical blunder at the hospital.

Lima Thatcher.

Lima Thatcher.

The internal papers reveal senior health officials believed the safety breaches were a ''significant risk for surgery patients'', and that compliance rates had become even worse by the end of last year.

But a senior hospital official defended his surgeons' conduct yesterday and said that an absence of documentation did not mean that the necessary safety checks were not being carried out.


In February last year, the auditors found that the pre-op safety checks had been completed in just 342 out of 1067 surgical procedures performed that month.

It was also found that despite surgeons being responsible for identity checks on patients - vital to ensure that surgery is not carried out on the wrong person - it was nurses who were mostly ensuring the checks were performed.

As late as March this year, executive director of quality and safety Elizabeth Trickett wrote in a memo that the audit results ''highlighted that safety checks are not always being performed. This is a significant risk for surgical patients and the organisation.''

The revelation will increase pressure on Chief Minister and Health Minister Katy Gallagher, who faces a motion of no-confidence in the Legislative Assembly brought by the opposition over her handling of the health portfolio. The Canberra Liberals described the latest documents yesterday as ''explosive''.

The audits were handed over by government solicitors to the family of Lima Thatcher, who are taking action in the Supreme Court to force an official inquiry into the circumstances surrounding the death of the 86-year-old, who endured botched surgery after a pre-op checklist was not completed.

Mrs Thatcher's granddaughter, Holly Chaloner, told The Canberra Times that she and her sister Kate were shocked when their legal team showed them the documents.

''We have to think again about what we were told by the hospital after seeing these statistics,'' Ms Chaloner said.

''We don't know how many other people this has happened to just because these simple checklists are not being followed.

''It's just astounding.''

But Health deputy Ian Thompson said that the audits measured compliance with documentation requirements and not the safety procedures themselves.

''What we're trying to do with these forms is trying to develop a more effective indication that these checks are being done, it is not an indication that the check are not being done, it is a question of whether or not the forms are being filled out.

''It's an audit of whether the forms are being filled out, it's not an audit of whether the checks are being done.

''We don't have any evidence or reason to believe that checks are not being done.''

Opposition Health spokesman Jeremy Hanson said the failings were systemic and that he was concerned with the hospital's own assessment that patients were being put in danger.


''The thing that concerns me is the systemic nature of this, the fact that 50 per cent, or thereabouts, of surgical patients at the Canberra Hospital are at significant risk, and that's the executive director of the compliance unit saying that,'' Mr Hanson said.

''That's a really disturbing figure and it flies in the face of everything we've been told by the minister.''

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