50 serious mishaps a year in hospitals
But they form a small proportion of the total number of admissions
By Lee Hui Chieh
A PATIENT about to get a kidney transplant almost received an organ of the wrong blood type at a hospital here last year.
The mistake was spotted and corrected in time, and the operation was carried out successfully.
How the national reporting system works
HOSPITALS are required by law to alert the Health Ministry to major mishaps within seven days and then make the necessary changes to prevent a recurrence.
The recommendations have to be submitted to the Health Ministry within 60days of the incident, and updates on the improvements made have to be given every three months, under what is known as the National Sentinel Event Reporting System.
It was the only near-miss of its kind reported in the last six years that came to light in a Ministry of Health (MOH) review of what can go terribly wrong in hospitals here.
Every year, there are about 50 serious incidents affecting patients, some of whom die, while others suffer permanent injuries.
The incidents include patients suffering falls, attempting suicide and even coming through surgery only to discover that a needle had been left inside the body.
Within the wards, other problems include misaligned feeding tubes. Outside of the wards, there have been incidents involving, for example, a procedure to unclog blocked arteries known as an angioplasty.
MOH received 302 such reports in public and private hospitals from May 2002 to December last year, through a national reporting system.
The mishaps make up a very small proportion of the total number of hospital admissions, an MOH spokesman said.
Last year, 58 major mishaps were reported out of a total of 429,744 hospital admissions, making for an incident rate of 0.01 per cent.
Information on every major incident was collected through MOH's National Sentinel Event Reporting System, set up in 2002.
Details of the findings, circulated every year among senior ministry and hospital officials, were presented to about 500 health-care professionals on Thursday, during the Lean Healthcare Conference on cutting waste and improving quality of health care, held by the National Healthcare Group.
Dr Serena Koh, the acting deputy director of MOH's health-care performance group, explained that the reporting system is made up of a network of quality assurance committees, which all hospitals are required by law to convene.
Each committee identifies the causes behind its hospital's major mishaps, and makes recommendations to prevent repeat incidents.
For example, cases of instruments left inside patients after surgery have prompted hospitals to look into tagging instruments so that they can be tracked using a wireless technology.
Dr Koh said: 'The committees do not focus so much on who's to blame, but on finding ways to improve.' i.e. There is no need for accountability. Let's move on.
Reporting a mishap to the committees by those involved does not grant them immunity from disciplinary action, she said.
If there is any suspicion of wrongdoing, the hospitals can still convene a committee of inquiry to investigate the cases.
The most common reasons for the mishaps occurring were poor communication between health-care professionals, followed by inadequate processes and not enough training, said Dr Aley Moolayil, assistant manager of MOH's clinical quality improvement.
Dr Koh and Dr Aley declined to elaborate on specific cases.
Madam Halimah Yacob, who heads the Government Parliamentary Committee (GPC) for Health, said that while some of the mishaps, such as the kidney transplant near-miss, were 'scary', the small number reported showed that hospitals here have high standards, a plus point also for making Singapore a medical hub.
'Overall, the results seem to be quite reassuring and such qualitative information would help to provide greater transparency to the public,' she added. 'However, there is always room for improvement and we cannot be complacent.'
Deputy chairman of the GPC, Dr Lam Pin Min, agreed: 'The accident rate of 0.01 per cent is very small, considering the large number of admissions to hospitals in a year. However, any accident will be one too many, and the ultimate goal will be to aim for zero accidents, if possible.' [email protected]
But they form a small proportion of the total number of admissions
By Lee Hui Chieh
A PATIENT about to get a kidney transplant almost received an organ of the wrong blood type at a hospital here last year.
The mistake was spotted and corrected in time, and the operation was carried out successfully.
How the national reporting system works
HOSPITALS are required by law to alert the Health Ministry to major mishaps within seven days and then make the necessary changes to prevent a recurrence.
The recommendations have to be submitted to the Health Ministry within 60days of the incident, and updates on the improvements made have to be given every three months, under what is known as the National Sentinel Event Reporting System.
It was the only near-miss of its kind reported in the last six years that came to light in a Ministry of Health (MOH) review of what can go terribly wrong in hospitals here.
Every year, there are about 50 serious incidents affecting patients, some of whom die, while others suffer permanent injuries.
The incidents include patients suffering falls, attempting suicide and even coming through surgery only to discover that a needle had been left inside the body.
Within the wards, other problems include misaligned feeding tubes. Outside of the wards, there have been incidents involving, for example, a procedure to unclog blocked arteries known as an angioplasty.
MOH received 302 such reports in public and private hospitals from May 2002 to December last year, through a national reporting system.
The mishaps make up a very small proportion of the total number of hospital admissions, an MOH spokesman said.
Last year, 58 major mishaps were reported out of a total of 429,744 hospital admissions, making for an incident rate of 0.01 per cent.
Information on every major incident was collected through MOH's National Sentinel Event Reporting System, set up in 2002.
Details of the findings, circulated every year among senior ministry and hospital officials, were presented to about 500 health-care professionals on Thursday, during the Lean Healthcare Conference on cutting waste and improving quality of health care, held by the National Healthcare Group.
Dr Serena Koh, the acting deputy director of MOH's health-care performance group, explained that the reporting system is made up of a network of quality assurance committees, which all hospitals are required by law to convene.
Each committee identifies the causes behind its hospital's major mishaps, and makes recommendations to prevent repeat incidents.
For example, cases of instruments left inside patients after surgery have prompted hospitals to look into tagging instruments so that they can be tracked using a wireless technology.
Dr Koh said: 'The committees do not focus so much on who's to blame, but on finding ways to improve.' i.e. There is no need for accountability. Let's move on.
Reporting a mishap to the committees by those involved does not grant them immunity from disciplinary action, she said.
If there is any suspicion of wrongdoing, the hospitals can still convene a committee of inquiry to investigate the cases.
The most common reasons for the mishaps occurring were poor communication between health-care professionals, followed by inadequate processes and not enough training, said Dr Aley Moolayil, assistant manager of MOH's clinical quality improvement.
Dr Koh and Dr Aley declined to elaborate on specific cases.
Madam Halimah Yacob, who heads the Government Parliamentary Committee (GPC) for Health, said that while some of the mishaps, such as the kidney transplant near-miss, were 'scary', the small number reported showed that hospitals here have high standards, a plus point also for making Singapore a medical hub.
'Overall, the results seem to be quite reassuring and such qualitative information would help to provide greater transparency to the public,' she added. 'However, there is always room for improvement and we cannot be complacent.'
Deputy chairman of the GPC, Dr Lam Pin Min, agreed: 'The accident rate of 0.01 per cent is very small, considering the large number of admissions to hospitals in a year. However, any accident will be one too many, and the ultimate goal will be to aim for zero accidents, if possible.' [email protected]
