A Queensland hospital has come up with a solution that raises the alarm if a test result or X-ray falls through the cracks.
A man dies after doctors fail to look at his X-rays, missing a chance to treat his cancer.
Another man suffers terminal brain damage. Nobody saw an X-ray showing his simple procedure had gone awry.
Yet another dies after doctors neglect to look at his blood test results.
These Australian cases are tiny examples of what happens when doctors around the world fail to look at crucial test results or X-rays.
But a Queensland hospital has come up with a solution that raises the alarm if test results and X-rays are not viewed by a specific deadline.
The system at Mater Mothers’ Hospital in Brisbane has scored a life-saving 100 per cent in a University of New South Wales (UNSW) assessment.
The study shows perfect follow-ups of 27,354 records for 6855 patients over a 13-month period.
“It is an unprecedented result,” says Associate Professor Andrew Georgiou from the Australian Institute of Health Innovation, which is based at the university.
No other similar systems around the world have achieved 100 per cent, says Prof Georgiou, whose study is published in the Journal of the American Medical Informatics Association.
“Hospitals are major logistical operations,” he says.
They operate 24 hours a day, seven days a week. Patients can spend time in numerous departments and are seen by a variety of doctors as shifts start and end.
He says crucial information often goes missing or is missed, particularly if there is a combination of paper and electronic record-keeping that lacks the checks and balances in the Mater system.
Previous UNSW research shows three-quarters of emergency department tests are not followed up.
In NSW 11 per cent of serious incidents, such as those that end in death, are associated with results that were either delayed or not reviewed, according to a 2011 NSW Clinical Excellence Commission report.
The same issue is blamed for a third of incidents that result in “major consequences”, such as loss of bodily function.