With more than 25,000 preventable deaths in hospitals around Australia each year, Dr Melanie Underwood has been working to analyse the causes of system failure, finding that nurse numbers are key.

As a nurse for eight years before becoming a lecturer with Charles Darwin University in 2011, Dr Underwood knows first-hand the trauma of patient deaths in hospitals and its effect on patients’ loved ones and staff caring for the patient.

“At the time of a death in a hospital a review is undertaken, but often there is no follow up with staff at the frontline of care to analyse the gaps in the system leading to the failure and how and why it happened,” she said.

“As nurses represent the largest group in the health care workforce, providing 24-hour care, they are in a key position to contribute to improving patient safety.”

Seeing a gap in the traditional review process and feeling a profound obligation to help find some solutions, Dr Underwood’s PhD research is the first Australian study to use coronial reports to analyse nurse-related adverse events resulting in the death of patients. 

By manipulating a system originally used by the US military to analyse failures resulting in adverse events called the “Human Factors Analysis and Classification System” (HFACS) she analysed 101 coronial cases.

Using 99 variables such as nursing shift, type of death, specific types of unsafe acts and environmental factors, she was able to drill down to how the behaviour of staff was impacted by the system.

“I found that almost all variables that had led to the deaths in each case were foreseeable and therefore often preventable,” she said.

“In the majority of cases, the number or skill mix of nurses was related to the unsafe act occurring.”

While she says the information surrounding staffing numbers is not new, particularly in remote and regional areas, the research reinforces this as a major issue contributing to preventable deaths. 

And it helps improve the understanding of potential system failures and their relationships to direct patient care activities.

“The research has confirmed that unsafe acts are not single, isolated events but the result of an error trajectory with influencing factors at all levels of an organisation,” she said.

“The factors contributing to error can be identified and mitigated which can then prevent deaths from occurring.” 

Dr Underwood is currently supervising further research using the HFACS framework to investigate the factors leading to inpatient suicide. 

She will graduate with her PhD at the CDU graduation ceremony on Friday, May 25.