Space weather...

[oneofsix]

You're right, but these days it is so much easier to explore new theories. I'm sitting in my study in Christchurch and I have access to databases from around the world and can access a depth of information that would have been inconceivable only a few years ago. And there are hundreds of thousands of bright young (and no so young) people desperate to make their mark and find something new, and that means existing theories are constantly revisited. People are always looking for ideas that have been explored and discounted in the hope of finding an angle that nobody else found, or of adding new knowledge to complete an incomplete study.

I'd love Ken Ring to be right because then life would be easier. Yesterday I was stuck in traffic on an overbridge, and quietly shitting myself because if another biggun hit I could well be in trouble, and I'd like to be able to lock the doors at night instead of leaving them unlocked so we can get out fast. If dear old Ken was right then I'd pack everything up and brace myself for the 20th, then get on with life knowing it was all over.

Working in Welly and living in Parm I'm praying he's wrong about the 20th.
Struck a chord with the comment on bridge, 4 of us were having coffee discussing the building structure, the quickest way to something we trusted and that it had to be within 2 metres, also on the walk back we were reviewing quake safety of were we were with some of the Welly buildings designed to drop there outer cladding in a quake. Also funny the other night watching the CNN front person presume people were safer outside in the city rather than in their homes in the suburbs.

[steve_t]

What a load of bollocks. Most/all herbal healing modalities are pooh poohed also by science. Plants used for millennia, useful, safe and free to grow....

Actually that's not true. A huge number of medicines are either synthesised compounds that occur naturally in plants or deriviatives of them. They are done that way because you can more accurately measure doses, isolate active ingrediants while avoiding harmful ingredients, and most importantly make money. Lots and lots of money.

And many medicines come from plants - opiates are a good example.

Exactly. For centuries the bark of the white willow tree has been used for medicinal purposes. Scientists analysed the bark and, what do you know, the bark contains salicylic acid - the same stuff that makes up Aspirin. Pain relief, blood thinning etc are wonderful properties of the stuff. So yes, there are scientific explanations for many plant extracts.
What I can't agree with is homeopathy where supposedly you can take 1kg of leaves of a plant, soak them in water thereby imparting the energy from the leaves to the water, mix that water with 100 litres of other water which 'teaches' the other water how to have the energised water's properties and then sell vials of that water for $$.
What makes it worse is the president of the Homeopathy Association of America claiming that a double blind, randomised controlled trial is not a valid way to test the effects of drugs/homeopathic remedies Anyone who has basic science training knows that it's the only truly impartial way to test something

[shrub]

Exactly. For centuries the bark of the white willow tree has been used for medicinal purposes. Scientists analysed the bark and, what do you know, the bark contains salicylic acid - the same stuff that makes up Aspirin. Pain relief, blood thinning etc are wonderful properties of the stuff. So yes, there are scientific explanations for many plant extracts.
What I can't agree with is homeopathy where supposedly you can take 1kg of leaves of a plant, soak them in water thereby imparting the energy from the leaves to the water, mix that water with 100 litres of other water which 'teaches' the other water how to have the energised water's properties and then sell vials of that water for $$.
What makes it worse is the president of the Homeopathy Association of America claiming that a double blind, randomised controlled trial is not a valid way to test the effects of drugs/homeopathic remedies Anyone who has basic science training knows that it's the only truly impartial way to test something

Yes, homeopathy kind of beggars belief. I wish it worked on my bank - if I deposit miniscule amounts of money I have the spending power of a brazillianaire.

[shrub]

Working in Welly and living in Parm I'm praying he's wrong about the 20th.

Praying will be enough to make him wrong - God outranks Ken Ring in the cosmic order, so Ken predicts an earthquake and then God gets a polite request to cancel the quake, and that's it for Ken.

[oneofsix]

Praying will be enough to make him wrong - God outranks Ken Ring in the cosmic order, so Ken predicts an earthquake and then God gets a polite request to cancel the quake, and that's it for Ken.

You presume I am only praying to one god Who was the Maori god for earthquake? the shame is I'm more likely to know the Roman or Greek gods for earthquakes but I don't know them either.

[rickstv]

The difference is that the Earth is somewhat larger than the moon while in the Jovian suituation Jupiter is somewhat fucking immenser than tiny little Io.

Io has a fairly true orbit around Jupiter, so jupiter doesn't have much effect on the
Io's core, BUT every two years, two of jupiter's other moons line up and give Io a gravitational kick. this is enough to melt Io's core over millions of years.

In Earth's case, the annual wobble and the influence of the moon has caused our core to become molten too. If the moon has this much effect on the core and tides, then I think it quite believable that the Moon may have influence on earthquakes in some cases too.
Rick

[RiderInBlack]

What a load of bollocks. Most/all herbal healing modalities are pooh poohed also by science. Plants used for millennia, useful, safe and free to grow.

Any Knowledgeable Herbalist will tell you that, like any medicine, herbs must be take in the right amount, in the right way, at the right time. To ASSUME all herbs are SAFE because they are natural is a good way to get yourself killed. Bit of Belladonna Tea anyone, it's Natural, How about some Death Cap Mushroom, Deadly Nightshade then? Fox-glove has Digitalis from which we get the drug digoxin from. In the right doses for the right patient, it's a life saver, but a killer if you get the wrong dose. I wouldn't go chewing on Fox-glove to replace Digoxin without know exactly how much was need. Tutu is another one, treat it properly and you get a strong healing Poultice. Do it wrong and you will get very sick.
So in short Herbal Treatment is NOT SAFE unless you know what you are doing. No different to any other Medicine in that fact.

[shrub]

You presume I am only praying to one god Who was the Maori god for earthquake? the shame is I'm more likely to know the Roman or Greek gods for earthquakes but I don't know them either.

I was more thinking Eric Clapton.

[mashman]

Is the globe not actually warming? I'm not up with the play. I thought the planet was warming but the bullshit was that humans were causing it. What's the latest?

Ken Ring's theory definitely deserves/deserved further research and data analysis. The theory is definitely plausible but unfortunately the data does not support the theory at this point in time. As much as I hated how John Campbell treated Mr Ring, I can't dispute suggestions that statements such as "an earthquake is likely to occur up to a week either side or a new moon or a week either side of a full moon" are so general that they cover every day of the month. Until there is further data to support the theory of the moon's influence on earthquakes, it will remain "busted"

Heh, i gave up caring, depending on what you read and where you read it you get different answers. Either way, the manipulation of the data, coz the scientists said it needed to be adjusted , doesn't give me any faith that either of the readings, for and against, are accurate... which is kinda funny considering it's a multi decade old science.

It depends on what questions the scientific community want answered I suppose. If you want an accurate reading, down to the day and region, then you're probably SOOL... but you could say the same of weather prediction, tornado prediction more so (yet shiloads of cash goes into it) and AGW (meh, pointless waste of money given the external influences that are being ignored) etc... I take your point, "busted" wise, but I would have thought there was enough to the theory that it warrants a serious looking into... but if scientists have already debunked the "theory" getting the answers to the questions they've already asked, they're highly unlikely to revisit the science... which is a crime... Guess we'll have to wait and see what happens on the 20th... I hope he's right, at least we'd have at least 1 reference point to kick the science off again, but I hope the quake happens somewhere benign...

To all: btw, the earth isn't round, it's a spheroid

[oneofsix]

I was more thinking Eric Clapton.

contemporary gods you are so right

[avgas]

Just to devils advocatise... Space and the lab are likely quite different. It's not just the moons affect on earth that needs to be taken into consideration. Do you not have variances/tolerances in your calculations? Does a man made object properlled into space always go where NASA expect it to?

Meteorologists have the same problems predicting the weather 1 day or a week ahead at times...

Not just his calculations . The indian engineer in scissors link has posted some of his predictions and also gives the reasons for not being able to pinpoint the exact location for where an earthwuale will strike.

Do you get the exact mileage out of your car that the book says? Have climatologists changed any data recently? Is the plastic Jesus "cult" just another fad? How do the government go over budget when they know exactly how much something is going to cost? After all, they are all experts in their own fields

Don't get me wrong. I am not critically reflecting on the science. More the person.

He comes across to what we in the engineering industry call "Bandaid solution bandit".
All cable ties, race tape and she'll be right attitude.
Walk up to him with a broken arm and he will try give you a bandaid.

In fact he reminds me of chicken little. Running around saying "the sky is falling the sky is falling"

Real doomsday scientists come forward and say
"The sky is falling on 21st December on 2012, as this is the day that I have calculated all the planets align and the gravity is strong enough to suck us into the sun - should all be over and done with by 3:15pm"

[scissorhands]

Any Knowledgeable Herbalist will tell you that, like any medicine, herbs must be take in the right amount, in the right way, at the right time. To ASSUME all herbs are SAFE because they are natural is a good way to get yourself killed. Bit of Belladonna Tea anyone, it's Natural, How about some Death Cap Mushroom, Deadly Nightshade then? Fox-glove has Digitalis from which we get the drug digoxin from. In the right doses for the right patient, it's a life saver, but a killer if you get the wrong dose. I wouldn't go chewing on Fox-glove to replace Digoxin without know exactly how much was need. Tutu is another one, treat it properly and you get a strong healing Poultice. Do it wrong and you will get very sick.
So in short Herbal Treatment is NOT SAFE unless you know what you are doing. No different to any other Medicine in that fact.

from http://www.solicitoradvice.com/medicalerrorstats.htm

Medical Error Statistics- In the NEWS



20.12.10



Federal: New report from FRACS- 5,777 Australians died during or after surgery last year

Audit committee chairman Professor Guy Maddern, who examined the deaths for the Royal Australasian College of Surgeons (RACS), says that a lack of hospital facilities is a problem that needs to be addressed. Of the deaths that attracted closer scrutiny, the auditors made significant criticisms of how 1 in 10 of those patients was managed. They found that case management contributed to 4 per cent of those deaths.

Source: abc.net.au 20.12.10.



28.01.10

NSW: Public Hospitals in NSW have the worst figures for medical error in the country

New Productivity Commission figures on ''sentinel events'' - severely harmful incidents that occur due to a failure of hospital systems - showed 59 cases in NSW, compared with 28 in Victoria, the next worst-performing state, and 147 nationwide.

Even accounting for NSW having the largest population and the largest number of hospital admissions, the figures still show the state performing worse than the rest of the country.

The figures, from 2007-08, represent a significant deterioration from a year earlier, when NSW was one of the best states, recording only 32 events.

The data showed:

* 18 NSW procedures involving the wrong patient or body part (29 total, nationally);
* 19 NSW cases of medical instruments being left in patients after surgery (37 total nationally);
* medication errors in NSW killing 17 patients (29 total nationally).

Professor Rick Iedema, of the University of Technology, Sydney, said the sharp increase was likely to be a result of both more incidents and more rigorous reporting.

Shadow health minister Jillian Skinner accused the government of under-investment in technology that could help reduce sentinel events.

She said barcode technology used elsewhere in the world to prevent medical instruments being left inside people should be used in NSW.

Source: SMH online 28.01.10; 29.01.10.

30.10.08



Federal: Hospital Errors on the increase according to new study

Hospital mix-ups over patient identity and body parts more than doubled in one year to 159 in public hospitals, the Australian Commission on Safety and Quality in Health Care has found. Mix-ups in private hospitals were also on the increase.

Source: SMH 30.10.08; The Australian 30.10.08.



Federal: One in Ten Australians are harmed by hospital treatment

Source: The Australian 28.10.08.



10.09.08



FEDERAL: New report says 1500 people die each year in Australian public hospitals because of overcrowding

A UNSW report for the Australasian College of Emergency Medicine also states that Perth’s big hospital emergency departments were the worst in the country for overcrowding.

Source: "Dying risk up 30% in crowded hospitals," The West, 10.09.08.



28.06.08

QLD: Blood Transfusion Errors

The Patient Safety Symposium at the Brisbane Convention Centre was also told that 117 "adverse blood events" were found after an analysis of Queensland Health's reporting incident system since December 2006. Patients given the wrong blood type can suffer severe allergic reactions, respiratory distress, excessive bleeding, kidney failure and death. Queensland Pathology transfusion expert Tony Ghent has developed a barcoded armband to alleviate confusion. The armband will be trialled at Royal Brisbane and Women's Hospital and the Gold Coast Hospital in the next few weeks. Source: news.com.au 22.06.08.



28.05.08

Report finds 10% of patients in Victorian Hospitals experienced a medical mishap/error.

A Victorian Auditor General's report has estimated that medical mistakes are made on ten percent of people admitted to the state's public hospitals. The report found 135,000 public hospital patients were subjected to medical errors in the last financial year. Source: abc.net.au.



27.12.07

S.A: Complaints against Doctors soar
The number of complaints against doctors in the public and private systems rose from 152 last year to 175. The complaints are listed in the Medical Board of South Australia's annual report. The figures follow a report in The Advertiser last Friday showing more than 2200 medication errors had been recorded at the state's major hospitals in the past year. Source: The Advertiser 27.12.07.



20.12.07

VIC: AVOIDABLE hospital catastrophes killed 38 Victorians in the past year. REVEALED BY DHS SENTINEL EVENT PROGRAM, ANNUAL REPORT 2006-07

The deaths are a third higher than a year ago, and the highest recorded since the State Government set up the Sentinel Events Program five years ago. Non-fatal cases included: A patient who had a swab sewn into his chest during heart surgery and had to undergo an operation to remove the gauze. A crash victim given the wrong blood during resuscitation. The blood was meant for a patient in an adjoining bed. Twenty other errors involving surgery on the wrong patient or body part were reported. Instruments or other materials were left in eight patients. Three patients died from medication mix-ups. Key causes were flawed procedures (32 per cent), poor communications (18 per cent), human error (15 per cent) and poor health information (12 per cent).

Source: news.com.au 21.12.07; The Age 21.12.07.



NSW: Royal North Shore Hospital

A REPORT released yesterday reveals more than 500 mistakes at the Royal North Shore Hospital have lead to either serious injury or death to patients. Source: news.com.au 20.12.07.



06.10.07

QUEENSLAND: 38 more patient deaths

QLD: a health watchdog is investigating the deaths of 38 patients believed to have died from negligence or catastrophic failures in the medical system. Medical staff are facing criminal prosecutions over two of the deaths. The deaths were among 5067 complaints fielded by the independent Health Quality and Complaints Commission in its first year. Source: news.com.au 06.10.07.



10.07.07

Report shows Australian public hospital bungles are killing scores of people

According to the Australian Institute of Health and Welfare in 2004-05:

- 53 operations were performed on the wrong part of the body.

- 27 patients who had operations, had instruments, sponges etc left inside their bodies.

- 7 patients died from being given the wrong medication.

- Missing medical records or ambiguous or illegible documentation about a patient led to 35 of the errors and 32 were caused in part because of poor communication between staff or between staff and patients.

- The institute said staff factors including inadequate training contributed to 23 of the errors, and 54 occurred in part because of problems with or breakdowns in rules, policies and procedures.

- 5 mothers died due to avoidable errors during childbirth

- Australian hospital patients needlessly died or were put at serious risk at least 130 times.

The report covers the 759 public hospitals operating in Australia. It covers REPORTED hospital errors in public hospitals only. So if we take into account the number of unreported errors and negligence in the entire healthcare system including private practice, the statistics are in fact much higher. To read more click here...

Patient safety expert Stephen Bolsin said little had improved in the past decade.

"Safety breaches in Australian healthcare are killing more people than breast cancer or road accidents," Associate Professor Bolsin said. (Source: SMH 11.07.07)




Medicos defend record on patient mistakes
Melbourne Herald Sun, Australia -
By Jane Bunce DOCTORS and public hospital managers today defended their record after a new report found 130 serious mistakes occurred in Australia's public ...

Report shows 130 needless patient deaths
Sydney Morning Herald, Australia - 10 Jul 2007
Australian hospital patients needlessly died or were put at serious risk at least 130 times between 2004 and 2005, a new report shows. ...

Patients 'left with surgical equipment in bodies'
ABC Online, Australia - 10 Jul 2007
The first national report into hospital errors has found there were 130 serious mistakes made in Australian public hospitals in 2004 to 2005. ...

Blunders on hospitals' shame file
The Age, Australia - 10 Jul 2007
PATIENTS who found doctors had operated on the wrong limb or who had equipment left inside them are among 130 cases of serious medical mistakes covered in a ...

Hospital bungles are killing scores
The Australian, Australia - 10 Jul 2007
AUSTRALIA'S first national report into serious mistakes in public hospitals has found at least 130 avoidable instances in which patients died or were put at ...

Hospitals reveal mix-ups in surgery
Sydney Morning Herald, Australia - 10 Jul 2007
THE classic hospital horror case - surgery on the wrong patient or body part - also turns out to be the most common significant medical mistake in Australia ...


21.04.07


Public Hospitals are at their Worse. What is being done to fix the system?

In NSW up to 130,000 patients are being harmed or experience near misses each year. There are an estimated 8000 deaths in Australia each year as a result of medical errors, more than the annual road toll of about 1600.

SMH 20.04.07- Condition critical: the poor state of the NSW health system - National



26.01.07



MEDICATION errors at Royal Melbourne Hospital have doubled in the past four years.

Melbourne Health, which runs the hospital, recorded 1217 medication errors in 2005-06 compared with just 503 in 2002-03.

Medication errors affected 1.2 per cent of the total number of patients treated at the hospital in 2005-06, compared with 0.6 per cent in 2002-03.

Melbourne Health also received its highest number of complaints in 2005-06, with 815 -- up from 603 in 2004-05.

(Herald Sun, 26 January 2007) ; [Melbourne Health Quality of Care Report 2005-06]



21.12.06



Harmed in NSW hospitals: 500 errors a record

ALMOST 500 medical errors in NSW public hospitals either seriously harmed patients or could have done so in 2005-06 - the highest number in the three years the statistics have been collected.

A report by the Clinical Excellence Commission found policies and procedures were to blame for a quarter of the errors and near misses. These included inadequate training requirements for some staff. Another quarter were attributable to communication problems, particularly when patient care was handed over to a different medical team or between shifts.

Incompetence or outdated skills were behind almost 100 cases, and inadequate ratios of medical staff to patients, or rostering of junior doctors into senior roles, was at the heart of about 70 of the problems. Equipment failure was much less common.

Serious incidents in NSW:

- Delayed or wrong treatment or diagnosis: 178

- Suicide outside hospital: 137

- Birth problems: 37

- Wrong operation: 36

- Falls: 30

For further info:

Sydney Morning Herald 21.12.06

Clinical Excellence Commission



18.10.06

Call to probe all maternal deaths
Coroners should investigate every death of a woman during pregnancy or childbirth, says a medical adviser Associate Professor James King, to the State Government.

A report by the Australian Institute of Health and Welfare shows there were 95 maternal deaths between 2000 and 2002, a rate of 11.1 women in every 100,000 who gave birth. This was up from 8.4 per 100,000 women in the previous three years.

The report said that of the 95 maternal deaths, 84 were related directly or indirectly to the pregnancy's management.

(The Age 18 October 2006) [AIHW: Maternal deaths in Australia 2000-2002]



05.10.06



Medical Errors in Victoria: 29 deaths connected to medical errors

A patient given the wrong dose of a sedative was among 29 people who died because of errors in hospitals that were reported to authorities last financial year.

The nurse administering the drug was unfamiliar with it and was not being supervised, according to State Government documents. When the medication error was identified, there was a delay in contacting medical staff.

The 29 deaths are among 91 serious medical errors that Victorian hospitals reported in 2005-06. The incidents are referred to as "sentinel events" and are defined as relatively infrequent, clear-cut events that reflect deficiencies in hospitals. There were 25 cases reported in which a procedure involved the wrong patient or body part, and six cases of instruments or other material being left inside patients, requiring more surgery to remove them. Medication errors led to the deaths of two patients. Seven medication errors did not result in deaths.

But the 91 incidents are believed to be a fraction of the serious errors in hospitals, many of which go unreported. While the number is lower than the 122 incidents, including 34 deaths, that hospitals reported in the previous year, authorities say that does not necessarily mean the true number of errors has gone down.

(The Age, 5 October 2006)



29.09.06



Patient deaths report transparency urged

The Health Consumers Council of Western Australia has called for greater transparency in the reporting of patient deaths and permanent injuries caused by hospital errors.

A Health Department report released yesterday shows 42 hospital patients died or were left with permanent disabilities in the past financial year as a result of clinical errors.

(ABC News, 29 September 2006)
[The Second WA Sentinel Event Report 2005-2006 [pdf 759kb]]



30.08.06



BAD MEDICINE

Another week, another appalling medical misadventure ... Why the hospital system is in crisis and what must be done to protect us. Julie-Anne Davies reports. (Bulletin, 30 August 2006)- excellent article. Excerpts from this article-

Just last week, it was revealed that up to six people in northern NSW may have died because a pathologist misdiagnosed their tests, and another 38 received the wrong treatment for a range of diseases, including cancer. Incredibly, Hunter New England Health waited eight months before investigating Dr Farid Zaer, who had already been sacked by another area health service. Only days earlier we learnt that Sydney doctor Suman Sood, who was convicted of two counts of unlawfully giving abortion drugs to a young woman, had a history of complaints, investigations and legal action against her. In the wake of the disaster – and as many as 87 patient deaths – that marked Dr Jayant Patel’s two-year career at Queensland’s Bundaberg Hospital, are we any closer to properly policing incompetent or downright dangerous doctors?

Shirley Byrne should not have died. In medical terms, the 74-year-old Manly grandmother’s bowel cancer was unremarkable, and the surgery to cure it routine. But by the time she was wheeled into the recovery room at Ryde Hospital, in Sydney’s north-west, around 5.30pm on February 4, 2000, she wasn’t breathing and nurses could detect no pulse. Her heart had stopped beating.

For more than half an hour her anaesthetist, Gerrit Reimers, refused pleas from nurses to begin resuscitation. By the time another doctor arrived and took over, it was too late. She suffered severe and irreversible brain damage and died three days later. As a Medical Tribunal later found, Reimers’ actions had “at least” contributed to her death, describing them as a “gross departure from appropriate standards of conduct”.

As part of a broader investigation prompted by Byrne’s death, Reimers was found guilty of 13 counts of professional misconduct, which included stealing and self-administering the powerful opioids pethidine and fentanyl, and treating patients while under their influence. The complaints, brought by the NSW Health Care Complaints Commission, spanned from 1996 to 2000 (when he was suspended from practice) and involved nine patients at a number of Sydney hospitals.

Valmai Kilmartin, a 69-year-old woman who died at a Melbourne hospital three years ago, after a nurse accidentally injected her with lethal potassium chloride instead of saline. The drug vials looked almost identical. The tragedy had happened before, with at least two other deaths in similar circumstances in Victoria alone since 1992. In 1995 Johnstone recommended that changes to packaging be introduced. It was ignored. Finally, following Kilmartin’s death, the drug manufacturers redesigned the ampoules. Too late for Roy Kilmartin, though. In a humbling submission to his wife’s inquest, he summed up in a few words what Johnstone says he has spent his working life attempting to articulate.



29.08.06



Medical errors 'killing thousands'

The number of deadly errors occurring in Australian hospitals has probably not changed in the past decade, despite reforms and millions of dollars being thrown at the problem, an expert says.

Report author, Dr Ross Wilson says that ten years later, in all likelihood, the figures are the same.

(SMH/AAP, 29 August 2006)



26.08.06



System error reports ring early alarm bells

Crunching the numbers on what goes wrong in hospitals is giving safety experts a useful means of making medicine safer. Excerpt from article by Adam Cresswell, The Australian.

The Clinical Excellence Commission was launched in August 2004 and began encouraging doctors, nurses and other health care workers throughout the state's health system to notify any adverse events. These are broadly defined as any negative events - not merely those that harm patients, but also those that have the potential to cause harm but are detected in time. Even reports of lost property and complaints about staff rudeness are included in the count.

Because the Incident Information Management System (IIMS) started getting going mid-way through the 2004-05 year, the full-year figures did not reflect the true experience. The year just ended, 2005-06, was the first 12-month period for which full data was available (although, as the notification to the system is voluntary, the true level of incidents is almost certainly higher).

An analysis of that first full year's data showed there were at least 125,000 notifications of adverse events, about 70 per cent of which (88,000) were clinical - in other words, excluding the category that includes lost property and administrative matters.

About 18,750 incidents resulted in some level of harm to patients. The biggest category of incidents was falls, representing 26 per cent of all notifications - 32,500 incidents. Twenty per cent occurred in a geriatric unit, and 18 per cent and 14 per cent in a general medicine unit and rehabilitation or stroke unit respectively. Over half (65 per cent) of the patients were aged 70 to 95, and 70 per cent either tripped, slipped or lost their balance.

The next biggest was medication errors. In many cases, as with all the categories of adverse events, the error was at the less serious end of the spectrum. An example would be where a patient was given a painkilling drug a few hours later than scheduled, which might leave the patient with inadequate pain relief for a period but would not cause any long-term damage.

Potentially more serious examples include the patient being given the wrong dose, or being prescribed the wrong drug altogether.

Medication errors accounted for 18 per cent of notifications, or 22,500 incidents. Powerful painkilling drugs such as morphine and oxycodone were most commonly involved in adverse incidents, followed by the heroin substitute methadone, insulin, the blood-thinning agent warfarin and the common painkiller paracetamol.

However, serious adverse events - those resulting in serious harm or death - are relatively rare. Hughes says there were about 500 a year, although the precise figure from the latest data is still being extracted.

Earlier attempts to identify specific numbers of serious events were able to quantify how often the most serious types of mistakes or accidents occurred.

There were 13 procedures involving the incorrect patient or body part in 2003/04, and 14 the following year. This might involve a patient having an operation of the wrong part of their body, for example on the left side instead of the right or vice-versa; but it also might be a patient being taken for an X-ray that was intended for another patient, or the scan being taken of the wrong place.

Another category, "retained instruments or other material after surgery", shows how the figures are being used to find problems and fix them.

It refers to scenarios where equipment such as scissors or swabs are accidentally sewn up inside a patient after an operation. There were nine such instances of this in NSW in 2003-04, and five in 2004-05.



23.08.06



The response of doctors to a formal complaint
Louise Nash, Bradley Curtis, Merrilyn Walton, Simon Willcock, Christopher Tennant
Australasian Psychiatry 2006 14:3 246 [Abstract]



21.08.06



18,000 patients in NSW harmed by hospital mistakes

Source: Adam Creswell- The Australian

THOUSANDS of patients a year are being harmed by often avoidable mistakes such as being given the wrong drugs, incorrect treatment or falling down while in the care of public hospitals or other parts of the health system.

An analysis, to be released today, of the first full 12 months of data from a NSW program designed to encourage reporting of so-called "adverse events" has found there were 125,000 notifications in the year to July 2006, of which 18,750 resulted in some level of injury or harm to patients.

NSW accounts for about one-third of the healthcare episodes across Australia, so on a national basis the figures could be expected to be three times higher.

NSW accounts for about one-third of the healthcare episodes across Australia, so on a national basis the figures could be expected to be three times higher.

But because reporting events to the system is voluntary, the true level of mistakes and problems in the public hospital system is likely to be higher still.

Falls represented the biggest category of adverse events, accounting for 26 per cent of all notifications or 32,500 incidents. Medication errors -- patients given the wrong drug or the wrong dose -- came next, accounting for 18 per cent of notifications or 22,500 incidents.

Incorrect clinical management -- in cases where the patients' conditions may have been misdiagnosed, diagnosis was delayed, or the wrong treatment given -- accounted for 13 per cent of notifications, or 16,250 incidents.

The figures were compiled by the NSW Clinical Excellence Commission, whose CEO Cliff Hughes will present some of the findings at today's Australasian Conference on Safety and Quality in Health Care in Melbourne.

Professor Hughes told The Australian that all but about 400 to 500 incidents a year resulted in minor or no harm to the patients. About 37,000 of the 125,000 notifications were of a non-clinical nature, such as lost or stolen property, or complaints over how a patient was spoken to.

However, he conceded many incidents could be prevented by better hospital procedures, and said the data was being used to change the times at which some common yet potentially dangerous drugs were given.

An example was the blood-thinning drug warfarin, which is commonly used to reduce the risk of strokes and heart attacks or for patients with irregular heart rhythm. Too large a dose could cause haemorrhage, while too small a dose meant the drug would not work, Professor Hughes said.

For historical reasons, such as the fact the results of blood tests ordered in the mornings would only be available in the evening, warfarin was usually given to patients at about 8pm to 9pm. But the figures showed a three-fold spike in adverse drug events at about that time.

NSW was changing procedures to have the drug administered at about 4pm, when more staff would be on duty to monitor effectiveness and handle adverse consequences, he said.

"That's a pretty good example of how this data can be used to drill down and look at the trends, and make changes in healthcare to make it safer for patients."

Professor Hughes said analysing the figures showed inadequate knowledge or skills on the part of doctors or nurses was linked to about 56 of the 500 or so serious adverse events. Over three times more (170) were due to communication issues -- for example, when key details about the patient's condition were not transferred to another ward or hospital department.

"Any adverse event is the end-point of some deficiency in the system," Professor Hughes said.

Source: Adam Cresswell, The Australian online.



18.08.06



'Culture of Medicine,' Not Fear of Malpractice, Prompts Physicians To Withhold Information About Medical Errors From Patients, Study Says
Physicians often fail to inform patients about medical errors because of the "culture of medicine," rather than because of concerns about malpractice lawsuits, according to a study published on Monday in the Archives of Internal Medicine, the Seattle Times reports.(Daily Health Policy Report, 18 August 2006)



26.07.06



Key to cutting medical errors

IN May, the The Australian reported that "senior doctors claim teaching hours for anatomy have been slashed by 80 per cent in some medical schools to make way for touchy-feely subjects such as cultural sensitivity, communication and ethics". The report stated that the Australian Doctors Fund had lodged a 70-page submission with the federal Department of Education, Science and Training "listing arguments from more than two dozen professors, consultants and medical academics for a rethink on medical education".

Although a reassessment of anatomy and other basic science teaching may well be valuable, it will be regrettable if this leads to a down-grading of education in effective communication for future doctors. Research evidence points less often to a lack of knowledge of anatomy among doctors than to poor management and communication as the causes of medical errors.

McCarthy and Blumenthal refer to research into medical errors that shows failed communication among professionals and low-quality teamwork are prime culprits that must be addressed in changing to what they term a safety culture.

Pre-operative briefing of the entire surgical team ahead of major operations promoted patient safety in experiments done by the Kaiser Permanente healthcare group in the US. Morale improved noticeably among staff and surgical errors and near-misses were reduced.

The published research on reducing medical error is dominated by evidence that nothing works as well as communication about intentions and risks among a therapeutic team led by an individual who understands risk and discusses this with all parties who have a material interest in, and capacity to influence, the outcome for the patient. This extends to the patient and their carer.

Communication skills are vital for the future practice of safe medicine in this country to an extent that may astonish some but which is well-known beyond the halls of medicine in every industry and business that has a concern about safety and quality.

See full article by : Stephen Leeder (Australian, 26 July 2006)

Stephen Leeder is director of the Australian Health Policy Institute at the University of Sydney and co-director of the Menzies Centre for Health Policy.

[Australian DoctorsFund:Submission on Australian Medical Education]



17.07.06



GP Medical Errors

Patients are the victims of mistakes during about one in every 1000 visits to a GP, but the threat to people's safety is probably under-reported, a new study shows.

These are the key findings from a series of studies published today in the Medical Journal of Australia. The issue is devoted to general practice to coincide with Family Doctor Week.

Report co-author Dr Meredith Makeham - of the University of Sydney - said 84 GPs working in NSW took part in the survey.

These medicos submitted 418 error reports, claimed more than 490,864 consultations under Medicare, and had more than 166,500 encounters with patients during a 12-month period.

GPs had reported making one mistake for every 1000 consultation billed under Medicare and two errors for every 1000 patients seen in a 12-month period.

Dr Makeham said the results indicated that a secure website where GPs could anonymously report mistakes was a practical way to collect this information.

"[But] it is very difficult to assess the proportion of errors that would go unreported even when a reporting system such as [this] is available," she said.

"A GP may not be aware that an error has occurred.

"GPs have been found to under-report adverse drug events and so other patient safety threats may also be under-reported."

Source: Danielle Cronin, (Canberra Times, 17 July 2006)

The Threats to Australian Patient Safety (TAPS) study: incidence of reported errors in general practice Meredith A B Makeham, Michael R Kidd, Deborah C Saltman, Michael Mira, Charles Bridges-Webb, Chris Cooper and Simone Stromer — Med J Aust 2006; 185 (2): 95-98. [Full text]


08.07.06



State blamed for 500 patient deaths

A SENIOR doctor has likened Premier Steve Bracks and Treasurer John Brumby to funeral directors for the way they are running the hospital system. Dr Peter Lazzari yesterday said about 500 Victorians died every year because of the system's shortcomings.

"We would calculate that at least half of those deaths are preventable," Dr Lazzari said.

Of the 500 deaths, some occurred while on waiting lists and others were the result of overcrowded hospitals.

"The government spokespeople said that these people would have died anyway," Dr Lazzari told 3AW.

"That flies in the face of what medicine and hospital care are all about.

"We're there to save lives, to improve life, to relieve pain, to relieve suffering.

"I actually relate this loss of life (to) Bracks and Brumby actually functioning like funeral directors."

Dr Lazzari, who represents Victorian hospital medical staff, said the hospital funding system did not take into account pain suffered by waiting patients, the deterioration of health, and deaths.

Source: Ashley Gardiner, Herald Sun online 08.07.06.



29.06.06



Star rating system proposed for hospitals

HOSPITALS should be given star ratings based on factors such as death and infection rates, to improve performance and help patients make better informed choices, a leading health academic says.

Giving the best hospitals a five-star rating would be one option. Another would be a league table ranking the best and worst performing hospitals, according to La Trobe University dean of health sciences, Hal Swerissen.

Hospitals could be rated as above, below or at acceptable standards.

See article by Carol Nader, Health Reporter http://www.theage.com.au/news/nation...174268817.html



05.06.06



Hospital mishaps cost $2bn

MEDICAL mishaps and patient complications are costing Victorian hospitals about half a billion dollars each year, with the financial burden nationally estimated to be $2 billion.

A study published in The Medical Journal of Australia that examines the number and cost of "adverse events" in 45 of the state's public hospitals in 2003-04, reveals that such incidents cost the health system $460.31 million.

And it warns that the bill could be higher, if flow-on costs once a patient is discharged, and adverse events in other Victorian hospitals not included in the study, are taken into account.

"Assuming other Victorian hospitals have the same adverse events profile, the cost of adverse events for Victorian weighted inpatient activity would be about $511.457 million per annum," the report said.

"As Victoria represents about 25 per cent of national hospital expenditure, the financial toll of adverse events for Australian inpatients is estimated at about $2 billion per annum."

Of the 979,834 patient admissions included in the study, the La Trobe University researchers found almost 7 per cent — or 67,435 admissions — reported at least one adverse event.

Patients with adverse events stayed in hospital about 10 days longer, and had more than seven times the risk of in-hospital deaths than those without complications.

But the authors note, it is not possible to determine from available data to what extent the complications contributed to death.

Hospitals define adverse events as incidents in which a patient is harmed while being treated. Increased costs associated with such events include longer hospital stays, additional drugs, and further treatment in theatre.

Former professor of health policy at La Trobe University, and co-author of the study, Professor Stephen Duckett, yesterday said acting to prevent the high number of incidents could result in "enormous" savings. Previous studies indicate that between 40 and 50 per cent of adverse events are avoidable.

Professor Duckett said while he was shocked by the huge costs to hospitals, he did not believe Victoria differed from other states. "This is not only a Victorian issue, but a national issue."

The study comes after an Australian Institute of Health and Welfare report released last week showed the number of incidents of adverse events in hospitals nationwide rose by 20,000 in the past year — from 319,321 in 2003-04 to 339,551 in 2004-05.

Australian Medical Association Victorian president Dr Mark Yates yesterday said remedial action should begin with revamping hospital IT systems, boosting doctor numbers and conditions, and reducing hospital overcrowding.

Victorian Health Minister Bronwyn Pike said the Government had increased resources to deal with adverse events, and encouraged openness in reporting hospital mistakes — becoming the first state to publicly release figures on adverse events.

But Ms Pike said the HealthSMART system — including electronic prescriptions — would not be completely rolled out for another three to four years.

Source of article- http://www.theage.com.au/news/nation...59609100.htmln

[The incidence and cost of adverse events in Victorian hospitals 2003-04 Med J Aust 2006; 184 (11): 551-555.]

[MisterD]

And yes, NASA know where there shit is going just fine.

Assuming they've not got their imperial and metric confused again...

[mashman]

Don't get me wrong. I am not critically reflecting on the science. More the person.

He comes across to what we in the engineering industry call "Bandaid solution bandit".
All cable ties, race tape and she'll be right attitude.
Walk up to him with a broken arm and he will try give you a bandaid.

In fact he reminds me of chicken little. Running around saying "the sky is falling the sky is falling"

Real doomsday scientists come forward and say
"The sky is falling on 21st December on 2012, as this is the day that I have calculated all the planets align and the gravity is strong enough to suck us into the sun - should all be over and done with by 3:15pm"

play the man not the ball why dontcha ...

Are we still talking about the Moon Man or Political Idol

3:15 eh... hope it doesn't wake me from my nap...

[avgas]

3:15 eh... hope it doesn't wake me from my nap...

With wellingtons "space weather" I imagine you should sleep through the end of the world no problems.