KEY POINTS:
League tables comparing the safety of hospitals are said to be a way of reducing the number of patients harmed through medical errors.
The idea is that hospitals would all aspire to a high rating - and that they would share information on mistakes, helping all to avoid
repeating them.
But medicine is as much art as science. Analysts of healthcare errors generally maintain that forcing doctors and nurses to report their own mistakes, rather than encouraging voluntary reporting and protecting their identity, would scare them off. The problem is driven underground. No-one learns. Mistakes are repeated.
Health workers might realise that a growing child with a breathing tube in his or her throat will eventually need a wider tube, or it might fall out. It seems obvious in hindsight. But if such a case actually happens and is reported - as it was, in the pile of event reports released by health boards yesterday - others can be warned to keep up a running check.
The Health and Disability Commissioner Ron Paterson has been holding a blowtorch to hospitals over their levels of safety and yesterday welcomed the Quality Improvement Committee's report on the number of serious and sentinel events at each hospital
But he does not want a league table comparing hospitals on those figures, which he says would be "too simplistic", unhelpful and forever weakened by the fact that some hospitals care for much more complex patients than others.
Instead, he wants a national system of comparison for specific data like medication errors, surgical infections and surgical deaths. He likens this to the British National Health System star-rating of its hospitals and schemes used in the United States.
He reckons it would identify problem areas and encourage hospitals to improve their performance. "It needs to be voluntary and for that to work, clinicians need to feel that they and their hospitals can do this safely, without there being a beat-up."
In part, he is reflecting the understandable anxiety of hospitals over "going public" with their mistakes. The focus on "quality" is still new-ish. The Cartwright inquiry nearly 20 years ago and the subsequent creation of the commissioner's office put patients and ethics at the centre of healthcare and a benchmark US study first put quality on the international agenda in 1991.
But only in the years following the publication of a similar study in New Zealand a decade later has it dawned on the health sector and public that things can be better than they are.