Report reveals hospital mishaps
A kidney patient bled to death at a community treatment centre in South Auckland after an alarm system was not activated because there was only one phone line.
The death was one of 115 unexpected and preventable incidents that harmed or killed patients in Auckland health facilities in the past year.
Nationally there were 360 events and Auckland District Health Board had the highest number in the country with 62. There were 24 incidents in Counties Manukau and 29 in the Waitemata region.
The Health Quality & Safety Commission today released its 2011/12 report on serious and sentinel events in the country's hospitals.
The report showed delayed medical treatment had become an "increasing trend" resulting in people needing more treatment, losing function or sometimes death.
A sentinel event is life-threatening or leads to an unexpected death or permanent disability, while a serious event is not life-threatening but requires extra treatment.
A report from the Counties Manukau District Health Board showed six deaths, including a kidney patient who died following haemodialysis at a community treatment house.
A review showed the patient may have not been told about the consequences of a significant post-dialysis bleed and there was only one phone line at the dialysis house, meaning when any phone was being used, the St John alarm system could not be activated.
There are now two phone lines.
The death was one of two at community dialysis centres last year.
Other deaths in the Counties Manukau area included the suicide of a mental health patient, and a stillborn baby who died after there was a delay in recognising and treating the patient's ruptured uterus.
Serious events included a patient with a spinal tumour who visited the emergency department four times without her condition being diagnosed.
Another patient was left with surgical tubing inside them.
In Waitemata, a 31-year-old patient had a heart attack while receiving dialysis and subsequently died. The death has sparked a review of satellite unit emergency response policy.
Also a 17-year-old had to have part of a finger amputated after a crush injury was not properly assessed.
Auckland District Health Board recorded 11 deaths, including a patient who died after receiving a bowel injury during gynaecological surgery which required multiple re-operations for infection. The case is still under formal review.
Serious events at Auckland included a person becoming blind in their only seeing eye after an administrative error delayed a follow up. Document handling processes have now been changed.
A platelet transfusion was also given to a wrong patient and a significant brain injury was caused by an overdose of anaesthetic. Reviews prompted changes in both cases.
Not all the events in the year to June 30 were preventable, but "many involved errors that should not have happened," the commission's chairman Professor Alan Merry said.
"In some tragic cases errors resulted in serious injury or death. Each event has a name, a face and a family, and we should view these incidents through their eyes."
"This is not about apportioning blame," he said. The total amount of events was down three per cent from the 2010/11 year, and while that was a positive step, Merry said too many people were still being harmed while receiving health care.
"This is about learning from our mistakes and making our health and disability services safer so patients receive the care they need, without needless harm. This report contributes to that by stimulating discussion about adverse events and identifying areas for improvement."