A report looking into the safety of patients in New South Wales hospitals has highlighted 452 serious incidents, including many that resulted in injury or death.
Of the incidents 157 were clinical management errors, such as misdiagnoses, post-operative complications or sending patients home too early.
Nine patients had surgical instruments left inside them, and doctors operated on the wrong body part or performed the wrong procedure on 13 patients.
Two patients died after receiving the wrong medication.
Health Minister Morris Iemma says the state's hospitals are generally very safe.
"This is a report on the most serious of those, 452 in the context of one and a half million patient admissions and 25 million services provided from our public hospitals, so the report shows that mistakes do occur but they're relatively small in number and it's a system that works extremely well," he said.
It is the first time the state's hospitals have had to count and report all serious incidents and Mr Iemma says it is part of a new push to get health professionals to report their mistakes to stop them from happening again.
"Something that's not being reported, it doesn't mean that it isn't happening," he said.
Mr Iemma says he takes the results of the report seriously, but he will not be naming individual hospitals.
"A simple league table of statistical information and statistics put against a hospital are not consistent with a culture of having the staff open in where mistakes are occurring so we can use that as a basis for improving," he said.
Increase
He says he expects reports of serious incidents affecting patients in hospitals to increase over the next year as more health professionals record incidents as they adapt to a new mandatory reporting system.
He says the department is looking to implement a new system of safety checks by March.
"Having two people review [cases] as opposed to one.
"Secondly the actual surgical team, that's the team in the operating theatre, prior to commencing a procedure go through what's called a time out - so before you start, take time out and double check everything," he said.
Opposition Leader John Brogden says the report shows the Government needs to change the way it allocates funding for the state's health system.
"We need to slash the bureaucracy and direct those funds to frontline medical services," he said.
"Until that happens, we'll continue to see plenty of public relations officers and plenty of bureaucrats and managers, but not enough funds to the frontline medical services."
An associate professor of ethical practice at the University of Sydney's school of medicine has welcomed the report.
Associate Professor Merilyn Walton says unless mistakes are reported, changes can not be made to the system.
"We need to know where the problems occur, but then we need to change the system to prevent it happening," she said.
"And that's going from everything from education and training of the work force through to redesigning how we deliver health care services."
452 serious incidents that occurred during 2003 and 2004 have been brought to light, by a report released today about the safety of patients in the hospital system in New South Wales, Australia. Many of the incidents highlighted by the report resulted in injury, or even death.

The report detailed 13 patients who had operations that they were not meant to have or who had the wrong part of the body operated upon. It also noted that another 22 were seriously injured in falls in wards and bathrooms.

Other statistics included four suicides in hospital, with another 128 occurring in community care. Another nine people retained surgical instruments or materials inside them after the operation. The rest of the serious incidents related to labour and delivery problems (26) and clinical management problems (157).