A patient at a Melbourne hospital was seriously harmed during a recent heart surgery due to a piece of equipment malfunctioning. The incident occurred at the Austin Hospital in Heidelberg while the patient was on cardiopulmonary bypass, where a machine takes over the heart and lung functions. The hospital has reported the incident as a sentinel event, which refers to a preventable adverse safety event resulting in serious harm to the patient, to Safer Care Victoria – an office focusing on healthcare safety within the state’s health department. The patient survived the incident and is currently in a serious but stable condition, according to Austin Health. The hospital has identified the device involved in the incident and removed it from clinical use. Investigations have determined that human error did not play a role in the malfunction.
The Austin Hospital in Heidelberg briefly paused elective cardiac surgeries following the incident, but there were no delays as procedures were accommodated elsewhere. Emergency cardiac surgeries continued as scheduled during this time. The hospital has stated that the device involved in the malfunction will no longer be used for future surgeries at Austin Health. The incident has been thoroughly investigated by the hospital internally and has now been handed over to Safer Care Victoria for further review. Although human error was ruled out as a contributing factor, the cause of the equipment malfunction is still under investigation.
It is concerning that such a critical incident occurred during a routine surgical procedure, leading to serious harm to the patient. The hospital’s response to the incident, including swift identification of the device involved and removal from clinical use, demonstrates a commitment to patient safety. The decision to pause elective surgeries briefly to ensure that similar incidents do not occur in the future shows responsible and proactive management by the health service. It is essential that hospitals prioritize patient safety and take immediate action to prevent such incidents from happening again.
Safer Care Victoria plays a crucial role in overseeing healthcare safety within the state, and their involvement in investigating this incident will help ensure accountability and transparency. The patient’s survival following the incident is a positive outcome, but it is essential to address the root cause of the equipment malfunction to prevent similar incidents in the future. The hospital’s commitment to cooperating with investigations and taking necessary precautions, such as removing the device from clinical use, is a step in the right direction towards preventing future harm to patients during surgical procedures.
Overall, the incident at the Austin Hospital highlights the importance of maintaining a high standard of patient safety in healthcare settings. While it is reassuring that the hospital responded promptly to the incident and took necessary precautions, further investigation is needed to determine the exact cause of the equipment malfunction. Safer Care Victoria’s involvement in the investigation will help ensure transparency and accountability in addressing the incident. Moving forward, it is crucial for hospitals to prioritize patient safety and take proactive measures to prevent similar incidents from occurring in the future.
