Montenegro urgently needs a registry of adverse outcomes in healthcare, modeled after developed systems, such as the "never event" in the United Kingdom, whose goal is to learn from mistakes and prevent the repetition of the same failures.
This was assessed for "Vijesti" by the president of the Medical Doctors' Union, a physician. Milena Popović Samardžić.
The Ministry of Health, headed by Vojislav Šimun, does not answer questions about what the external commission of that department has determined in the cases of the death of a newborn in a Nikišić hospital due to choking on milk, as well as the boy from Bar and the thirty-seven-year-old man from Berane who died of sepsis after unsuccessfully seeking medical help for their ailments. Regarding these cases, the Higher State Prosecutor's Office in Podgorica and Bijelo Polje has opened cases that are in the investigation phase and forensic medical examinations are underway.
"Vijesti" also asked the ministry how many healthcare workers were suspended due to the three deaths, how many were fired, and which heads/directors of institutions were dismissed due to systemic responsibility. The Ministry of Health did not respond or say what they had done to prevent such incidents in the future.
Popović Samardžić explains that what everyone expects from the Ministry is a guarantee that the system has learned its lesson and reduced the risk of the same thing happening again.
The results of the independent investigation are persistently lacking.
Both the public and the profession are looking for meaningful results from an independent investigation, which are persistently lacking. What everyone expects from the Ministry of Health is proof that the system has learned its lesson and reduced the risk of the same thing happening again, Popović Samardžić assessed.
She believes that from what has been publicly announced so far, the following pattern is dominant: announcements, commissions and established phrases, without a clear assessment methodology and without visible systemic changes.
"Montenegro urgently needs a registry of adverse outcomes modeled after developed healthcare systems. In the UK, it is called a 'never event', the aim of which is to prevent the repetition of errors, to improve knowledge in areas where there was previously a deficit. These systems learn from their mistakes, while in our case, mistakes are repeated because the system does not learn and does not correct itself. Our system sacrifices people, especially those who are the weakest links in the system and without political support," Popović Samardžić pointed out.
She emphasized that in serious systems, cases like those that occurred in Montenegro at the end of last year are a reason to form an independent, expert commission, not a commission "from the same chain of command", with a predefined methodology and a report that must be concrete.
This report, he claims, must contain exactly what the points of failure were (triage, risk assessment, monitoring, communication, transport), what systemic factors contributed (number of staff, workload, organization of duty, availability of pediatrics/anesthesia, equipment, laboratory, protocols) and most importantly - what changes are being introduced (protocols, checklists, "early warning" score, mandatory escalation, supervision, training), along with indicators and deadlines that would show a decrease in the number of complications.
Responsibility only in announcements
A newborn baby, a few days old, died in a hospital in Nikšić at the end of October, and according to the preliminary autopsy findings, the death occurred due to suffocation with milk. The Higher State Prosecutor's Office in Podgorica launched an investigation and ordered a forensic medical examination, but the findings of the internal, hospital, and external commissions of the Ministry of Health in this case are not known to the public. In the meantime, two nurses have been dismissed.
According to the decisions on dismissal from work, which "Vijesti" had access to, the death of the newborn occurred during the shift of two nurses who were obliged to monitor the newborn, while from the submitted statements of all the actors in the event (due to contradictory statements), it cannot be determined exactly how long the baby was unattended.
A nine-year-old boy from Bar died in that city in mid-November, and the cause of death was determined to be bacterial blood poisoning - sepsis, as a result of a complication of chickenpox.
The boy died after the family visited several doctors in various public and private health institutions - two private ones in Ulcinj and Sutomore, as well as the Clinical Center of Montenegro and the Bar General Hospital. The Podgorica Higher State Prosecutor's Office has also opened a case regarding the boy's death, which is in the investigation phase.
"Vijesti" announced at the end of December that the Higher State Prosecutor's Office in Bijelo Polje is investigating the death of a patient (36) treated at the Berane Clinical Hospital Center, who died in November from sepsis - after his colon ruptured during an examination at that institution.
Family of the deceased ND In a letter to "Vijesti", he claims that obvious and alarming symptoms, as well as the scans taken, were ignored, which led to the death.
Regarding all three cases, the Ministry of Health issued statements, claiming that after completing the work of the external commission and receiving the findings of the competent authorities, it will promptly inform the public about the established facts and any measures taken.
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