In the context of the nearly 3 million patients treated in public hospitals in the past year, the fact 360 suffered an adverse event is not cause for panic. However, that does not detract from the very real harm done to the victims, often as a result of avoidable mistakes, delays or accidents.
OPINION: As Health Quality and Safety Commission chairman Alan Merry notes, behind each event is a "name, a face and a family". Ninety-one patients died after being involved in mishaps reported to the commission in the year to July 1. Although some of the deaths were not necessarily a direct result of the incident, most were.
In other cases, patients unnecessarily underwent traumatic surgery, such as a woman in the Southern District Health Board who was wrongly given a mastectomy after slides sent to a private laboratory were mixed up. In 17 cases, there were unacceptable delays in patients getting essential treatment.
The publication of adverse events has been an important step in opening the health system to public scrutiny. At its core is the right of taxpayers to information about the hospitals they fund, details DHBs have in the past point blank refused to supply.
It took this newspaper more than two years and two appeals to the Ombudsman to get the first information on serious and sentinel events from the Capital and Coast District Health Board in 2007.
Even then, the DHB tried to bully the newspaper out of publishing the data, claiming it would deter people who needed medical treatment from seeking it and encourage medical staff to close ranks and cover up mistakes.
How times have changed. The arguments advanced five years ago for keeping information on major errors in the hospital system from the public never stacked up, as the collection, monitoring and active release of incidents by the commission shows. And, in stark contrast to its former secrecy, Capital and Coast deserves praise for the level of detail it now provides about events in its hospitals, including the reason they occurred and, most importantly, measures put in place to prevent mistakes being repeated.
That is as it should be. The point of gathering and issuing data on serious and sentinel events is not to name and shame DHBs or individual hospitals, nor to play the blame game.
Again, as Prof Merry notes, the object of the exercise is to make the hospital system safer by acknowledging errors when they occur, analysing what went wrong, learning lessons and sharing best practice across the system. As part of that effort, DHBs have been required since July 1 to report the findings and recommendations of their reviews into such events. That information will allow future reports to discuss contributing factors and initiatives that might help other DHBs avoid the same mistakes or oversights.
New Zealand is well-served by the professionals who staff its hospitals, but they are only human. Mistakes and accidents can never be fully eliminated. However, they can be limited. The key to that is sharing information on what went wrong, and what can be done to prevent it occurring again.
- The Dominion Post