The vast majority of incident reports documenting problems at Canberra Hospital were inadequate, missing information or used inappropriate severity ratings, an internal audit has revealed.
The audit, obtained under Freedom of Information laws, was completed in November 2015 and raises concerns for patient safety and the quality of investigations into incidents to prevent them recurring.
It also revealed one case where a terminally ill patient was forced to undergo a second surgery to correct a previous surgical error, which reduced the patient's quality of life.
But the incident report in the Riskman system rated it as "insignificant" and it was not referred for clinical review or reported to the hospital's Clinical Governance Forum for investigation.
It was one of up to 79% of ratings recorded in 2014 that ACT Health internal audit team found were "not clearly appropriate", which could lead to "poor decision-making" on potential investigations.
The auditors analysed 25 out of 11,670 incident reports filed in 2014, finding up to 96 per cent were incomplete and missing information about investigations completed and "actions taken" and up to 75 per cent were "unclear or inadequate".
Some 70 per cent of Canberra Hospital and Health Services staff interviewed as part of the audit also believed the incident reports were not "complete or accurate" records.
While the auditors wrote the analysis was "statistically significant", an ACT Health spokeswoman described it as "a subjective review [that] was then extrapolated to all incidents to obtain the figures".
Problems with hospital reporting systems are not unique to Canberra and the spokeswoman said several changes had been made, or were underway.
Those changes included reviewing and updating the incident management policy, more staff training, restructuring the hospital's patient safety team and adopting a new best-practice "clinical review tool" to help identify incidents that my need "further discussion".
But the union representing doctors at the hospital, and consumer advocates, say the problems persist.
Australian Salaried Medical Officers Federation ACT secretary Stephen Crook said the audit raised issues about the reliability and timeliness of data reported on incidents, and "how much notice is taken of it".
"There's not a lot of trust in the system, it's slow and clunky and the way things are reported varies - what one person sees as a critical issue another doesn't, particularly as you go up the chain," he said.
Healthcare Consumers Association ACT executive director Darlene Cox said there was "a culture of under-reporting" incidents and often it was nurses and allied health staff reporting, rather than doctors.
"We're also concerned that collecting the data is one thing, but unless you act on it, there's almost no point in collecting it," she said.
"Consumers wear all the risk and we think that one of the big ways you could improve compliance is by making the patient's notes available to them and their family."
An ACT Health spokeswoman said more staff training for incident report was now being conducted, with about 20 "education sessions" a month, reporting was now mandatory for "responsible managers" and the hospital was adopting national standards for rating the severity of incidents.
"Providing a safe environment for our patients and staff is our number one priority," she said in a statement.
"As part of this, we actively encourage all staff to report all incidents and use this information to make continual improvements to clinical care, patient safety and organisational learning."