By Salma Khalik

ONE patient had the wrong knee replaced while five others had swabs left in them after surgery.

Theirs were among the 401 hospital errors reported to the Health Ministry over the past seven years, since reporting was made compulsory in 2002, or roughly one every week.

According to the ministry, public hospitals, with heavier caseloads and more complicated cases, made 339 reports and private hospitals 62.

The bulk of the errors are linked to surgical procedures, though they are not always the most serious, said Dr Lee Chien Earn, senior director in charge of health-care performance at the ministry. A recent report made early last month, for example, involved two patients at KK Women's and Children's Hospital (KKH) being given chemotherapy drugs over hours instead of days when pharmacists mixed up daily and hourly pumps.

In the past, these incidents would have been kept private within the hospital. To ensure no learning opportunities were lost, the ministry made it compulsory for hospitals and doctors to own up but promised anonymity.

No one is identified when a mistake is reported. Nor does the ministry pursue those at fault. That is left to the hospital or patients to deal with.

Hospitals have a week to report mishaps, and two months to report steps put in place so similar mistakes do not happen again. The penalty for not reporting a case is a $2,000 fine and/or imprisonment of up to 12 months. A hospital that repeats the offence could have its licence revoked.

Sentinel systems exist in most developed countries, starting with the United States in 1996. Countries even share their experiences. For example, hospitals here no longer store bottles of concentrated medicine in their wards after 10 patients in the US died when they were given concentrated potassium chloride by mistake.

While not all adverse incidents are a result of error - for instance, patients could have severe reactions from drug allergies that they were unaware of - they all have a negative impact on patients, sometimes even causing death.

The goal of sentinel systems is to learn from mistakes and rectify them.

In the KKH chemotherapy mix-up, the ministry immediately sent out a warning to all hospitals, recommending that they use only one type of pump, and to label them more clearly.

Other errors have also led to glitches being fixed. One of the biggest risks in hospitals is operating on the wrong part of the patient. This has happened five times in the last four years, including the patient who had the wrong knee operated on.

Hospitals have since introduced an obligatory 'time-out', for the surgeon to talk to the patient while he is awake, to make sure he has the correct patient, procedure and site.

Not all mistakes have obvious solutions, said Dr Lee, or there would not have been the five cases of swabs left in a patient after surgery.

Swabs left in are discovered only if a patient develops an infection later, or if they show up on a subsequent X-ray.

Some hospitals are trying out a method to tag all swabs with smart chips so they can be tracked by computers.

Several hospitals said they approved of sentinel reporting and are constantly on the alert to improve their systems.

Said Associate Professor Quek Swee Chye, deputy chairman of the National University Hospital's medical board: 'It is about creating better systems, and putting in place checks to eliminate future events.'

Alexandra Hospital's Associate Professor Koh Kwong Fah, its medical board's acting chairman, noted: 'The sharing across hospitals promotes learning and improvements. We are trying to promote a non-punitive, just culture rather than a blame and shame culture.'

Dr Lee added that with each event, the quality of care improves. He said: 'We're constantly raising the bar.'

This article was first published in The Straits Times.