Patient put under the knife after staff mixed up results
Published 24/01/2012 | 05:00
AN UNLUCKY patient underwent major surgery which was unnecessary after hospital staff mixed up test samples, a new report has revealed.
The blunder was the subject of one of 166 successful claims for medical negligence against the State in 2010 which resulted in an 'out of court' compensation payout.
While full details of the cases were not revealed in the State Claims Agency report, more than half the payouts related to mistakes made during surgery or while patients were in the care of hospital emergency departments.
In another settled case, a patient's results were inadequately reviewed, causing a lack of treatment and "catastrophic consequences".
More than one-in-four of the mistakes related to a wrong diagnosis and almost one-fifth were due to the nurse or doctor's own error.
In cases where the practitioner was at fault, problems with skills, competency and knowledge came to light.
The report said in one case there was a failure to recognise the patient was deteriorating and this resulted in delayed surgery.
In the case of another patient, there was an incorrect diagnosis by two different hospitals and the patient later developed peritonitis -- an abdominal infection, which left them spending longer in hospital.
Other patients had their organs punctured during surgery and had to go back on the operating table again.
Other weaknesses include communication failures, lack of effective leadership, a lack of safety culture, the non-availability of guidelines, a lack of supervision and staffing levels.
The report pointed out: "In recent times there has been an increasing awareness of requirements to more readily identify deterioration in a patient and ensure this is communicated effectively to the relevant healthcare practitioner.
"A large body of evidence continues to demonstrate that patients who become acutely unwell on general wards may receive suboptimal care."
Action taken during early stages can prevent deterioration that may often progress to cardiac arrest and death.
The report said these failures have become "discernible" in claims managed by the State Claims Agency.
The report warned that communication and teamwork among health staff is also essential to recognising a patient is deteriorating.
It said that mistakes made around the time of childbirth accounted for 12pc of all settled cases during the year and some of the problems arose from inadequate assessment or poor standards of documentation.
All of the cases and trends are examined by clinical risk advisers whose job it is to ensure that education, training and guidelines are put in place to minimise areas of weakness.
The agency paid out a total of around €60m in compensation in 2010. However, this includes cases which were settled following a court hearing. Individual amounts for cases settled out of court are not available.