76 Deaths, surgical mistakes in New Zealand Hospitals

As one of the old blues songs goes, ‘I laugh just to keep from crying’.  This morning the headlines are out there nationally and internationally. MSN tells the story that in the YEAR ended July 2008, 76 people died out of a total of 258 incidents, that is those that we now about, in New Zealand hospitals.

The story says that the Ministry of Health’s Quality Improvement Committee went on to say that each of these deaths and incidents were avoidable.

The NZ Herald had the story on the front page of the printed edition, but semi buried on the net. They quoted the Health and Disability Commissioner Ron Paterson as saying that it was not a surprise and the story continued to say that ‘Reporting is voluntary and District Health Boards do not know how many incidents are unreported.

Incidents included people’s teeth being accidentally removed, 2 patients being given 10 times the needed dose of medicines, in at least one case, morphine, another patient was booked in, anaesthetised and sent to the operating theatre for an eye surgery they had already had 2 weeks prior. Mistaken identity is another common thread.

Does this come as a surprise to you? It doesn’t to me.

I wrote about these sorts of issues in this blog in February last year. I also presented one of the solutions that has been used in hospitals in the US for many years, at least 15 years ago when Welch Allyn (a well respected technology provider to the health industry) first brought out 2D bar code scanners with the ability to read complex bar codes on patient wrist bands and patient record folders, containing a huge amount of patient information, without requiring access to the hospital’s computer systems. All they would have needed was a number of scanners and a handheld computer such as a Windows CE device (which could also contain a database of things like drug interaction data, i.e. don’t use this drug in combination with that one.

Back in the late 80’s we were already able to come up with a solution that would keep track of patient records folders (which always seem to go missing when you visit the hospital) and are able to identify not only exactly what they are in hospital for, but also things like allergies (especially to drugs such as penicyllin) and any other relevant information such as blood type, currently prescribed drugs (both by their GP and in the hospital and much more.

I presented these concepts and more to Auckland Hospital and the Waitemata DHB. The solution was simple and low cost, but they chose the lower cost option of doing nothing.

So they saved some money and chose to ignore solutions which 20 years ago were strting to be installed in some hospitals in the US. How many lives could have been saved in those years?  I shudder to think. Of course there are also many living victims, who have had to have surgery repeated to remove items accidentally left in their bodies, or many of the other incidents. What about the family of those who died?

So I have a couple of questions:

• When everyone in the industry new these things have always happened in the industry, why was nothing done about it?
• Why is it voluntary to report incidents? Why isn’t it mandatory?
• How many more incidents actually occured that weren’t reported?
• What are they going to do about it?

You can read the damning report for yourself by downloading this pdf.

If you don’t want to, check out a few of these incidents from the report:

• Several mental health patients who committed suicide when they should have been under close supervision, or who were discharged and then killed themselves.
• A patient who died because of confusion over resuscitation status
• A patient who’s tests suggested cancer which was overlooked
• Accidental removal of a breathing tube from a ventilated patient
• Accidental bowel perforation during gallbladder surgery resulting in fatal multi organ failure
• Death of a mother from post partum hemorrhage due to a number of  ‘errors’

The list goes on for 84 pages and these are only those which were voluntarily reported!

So is the hospital the best place to be when you are sick? You decide.

Are there solutions? Yes there are and there have been for many years. I introduced some of them over 15 years ago and my ideas weren’t new, they were already being introduced into US hospitals at the time.

Are they going to do something about it? I hope so. My concepts don’t solve all the problems, but they could have saved several of these poor people and their families. Who is going to take responsiblity for this? I put it to you that the cost of the solutions is far less than the consequences of not using them at least 76 times over.

If you ask me, the government needs to step in now and do something about it. In many cases there are very simple technologies that will if implemented save many lives, but will also introduce sgnificant cost savings through eliminating some of the inefficiencies that waste time and money.

While this blog is starting to get a good following, I would love to get more readers and encouraging me to keep writing. If you feel that my blog is interesting I would be very grateful if you would vote for me in the category of best blog at the NetGuide Web Awards. Note that the form starts each site with www whereas my blog doesn’t and is of course https://luigicappel.wordpress.com.

Thanks so much for your support:)

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Is Vehicle Tracking (Fleet Management) an Invasion of Employee Privacy?

An interesting story originating from the Sydney Morning Herald last week, and doing the rounds in New Zealand, says that ‘Privacy Experts’ and Unions are saying that vehicle tracking systems used by companies are an invasion of staff privacy.

It goes on to talk about a former Telstra employee who committed suicide shortly after having a vehicle tracking system attached to his company vehicle. The employee was being treated for depression and the story infers that his suicide was in part a consequence of Fleet Management equipment being installed in his vehicle.

Over the last decade I have been in various ways involved with Vehicle and Personal Tracking technology and only once have I come accross a company that wanted it to be able to check up on the honesty of their staff.

There is no question that some companies have found a sudden increase in profitability and decrease in vehicle costs since they put FM systems in place, but monitoring staff integrity was not the reason the system went in. This particular company wanted to know which vehicles were close to clients that needed urgent service so that they could allocate the nearest vehicle to provide a quality reponsive service.

A few years ago I met the CEO of a rapid response plumbing firm. They guaranteed a minimum response time for people who needed a plumber in an emergancy. He was able to manage this as a consequence of using Navman Wireless technology to locate the nearest vehicle to the job.

They also wanted to compare time based service contracts to the actual time the vehicle was parked at the client site. They wanted to know if they had under or overquoted because there was sometimes a gap between the sales person’s enthusiasm to win a contract and the reality of the job being done.

What did happen was that a number of staff people whom they had suspected of taking liberties with the vehicle on the job and after hours, left the company within a month or so of their own volition.

I am against (and it may well be illegal) tracking people and their vehicles without their knowledge. The only people able to do that should be the Police and even then, only with a legal warrant produced through the courts.

On the other hand there are many potential benefits. In the courier and freight industry, Fleet Management means that people can easily apply track and trace to good being picked up and delivered without needing additional staff to place calls to drivers.

In the security industry it means that security guards on patrol can confirm the safety and location of their staff and also provide clear evidence to clients that their premises have been visited when they said they were. It can also mean that these people can be backed up in an emergancy. This technology is used internationally to track and protect the safety of VIP’s such as politicians in government vehicles.

Another area that is becoming popular is using this technology to keep track of a personal vehicle’s location. For example, when Dad lends the car to his son or daughter who is just popping down to the shops or a mate’s place, who could be boy racers. There have been a number of occassions where a stolen vehicle has been recovered with the thief still inside, such as the case earlier this year. Sometimes a car is irreplacable such as a classic, or sports car. Insurance money can’t always allow someone to recover the time spent in restoring or bulding a vehicle. This technology can also be used to secure trailer water craft and motorcycles which are often easy targets for criminals.

Another area which is becoming very popular and which I have written about a number of times before is tracking elderly people. With the Baby Boomers living longer and being more mobile, there is a growing population of elderly people, some of whom are sprightly of mind, but less of body and at risk of breaking hips or other body parts, while others are sound in body but suffering onset of Alzheimers Disease or other forms of dementia and likely to wander off and not remember where they live. Whether it is the Retirement Village or Rest Home, or their children, this common problem becomes much easier to manage if you can send a text message to the device they are carrying and receive one back with the nearest street address to their current location.

I think tracking is a great thing for unions to use to help them shore up membership and totally endorse them helping people out when it comes to unethical practice on behalf of the company they work for. However, in most cases FM (Fleet Management) is about providing better service to a company’s clients, being able to stay competitive in a time of heavy traffic, high cost of petrol and consumers who expect cheaper prices.

While this blog is starting to get a good following, I would love to get more readers and encouraging me to keep writing. If you feel that my blog is interesting I would be very grateful if you would vote for me in the category of best blog at the NetGuide Web Awards. Note that the form starts each site with www whereas my blog doesn’t and is of course https://luigicappel.wordpress.com.

Thanks so much for your support:)