Independent audits of surgical mistakes improves Vic hospitals
The annual report of the Victorian Audit of Surgical Mortality (VASM), which aims to improve surgical care into the future, has been released.
VASM is a clinical review of those cases where patients have died in hospital while under the care of a surgeon. Most Victorian hospitals providing surgical services are in the VASM process, and the number of Victorian surgeons actively participating has steadily risen to 71%.
Experience indicates that once an audit process is in place, the participation rate of hospitals and surgeons rises quickly.
Among findings in the 2009 Annual Report are:
- The majority of surgical deaths in this audited series occurred in elderly patients with significant underlying health problems, admitted as an emergency with an acute life threatening condition often requiring surgery;
- The actual cause of death was often linked to a patient’s pre-existing health status. Death was most often adjudged to be not preventable and to be a direct result of the disease processes involved and not the treatment provided;
- Major concerns were raised regarding clinical management in 4% of cases. However, in only four cases (0.6%) were these felt to have definitely contributed to the likelihood of death.
All criticisms of patient management have been formally directed to the treating surgeons for their consideration. This feedback is essential to the audit’s overarching purpose – the provision of ongoing education to surgeons and the improvement of surgical care.
Since the inception of the Western Australian Audit of Surgical Mortality all other Australian states have established their own audits, and the Northern Territory and the Australian Capital Territory are preparing to do so.
