"This sort of data ... gives us a platform on which to build an early warning system," Professor Hughes told the Herald. "I would expect that in 12 months' time we will see an increased number of reports ... because people will see the data can be handled sensitively and compassionately." The collection of information on patient deaths and injury in hospitals has long been a contentious issue at state and federal levels. Doctors have been accused of being unwilling to report errors regularly because of professional pride or fear of litigation, and governments have chosen to remain ignorant about deaths or injuries occurring in their hospitals.
"We have finally got our act together," Professor Hughes said. "We have got the will, from the clinicians and the system, to make it happen - it is a big change in the culture of health that we have applied over the last 12 months." He uses as an example the discovery, via hospital reports, of an instrument used to retract abdominal tissue during surgery that was left inside two patients following surgery.
NSW Health put out an alert to all hospitals regarding the instrument, to inform staff of the incidents and to remind them to ensure it was counted at the end of each operation. Next year's data would show whether the policy worked, he said. "What is learnt in one area by one hospital ... can be put out across the whole system quickly so we don't have to learn from our own mistakes, we can learn from the mistakes of others." In 1995 the Quality in Australian Health Care Study found between 10 and 16 per cent of all interactions with the country's health system resulted in harm, and that half were preventable. The NSW data is narrower in its focus - 452 serious incidents out of 1.5 million admissions to 206 NSW hospitals and health facilities staffed by 100,000 health workers - and represents an error rate of 0.03 per cent.
Professor Hughes said under-reporting of error was occurring, but hoped health workers would eventually report their mistakes without fear of retribution. The Health Minister, Morris Iemma, said the Government was committed to a policy of "open disclosure".
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).