Aiming for a perfect score

It's the kind of report that can make for pretty grim reading.

Each year, every district health board releases a document called the "serious and sentinel events" report. They catalogue each DHB's most serious and, in some cases, disturbing medical mishaps and mistakes.

When reading these reports it would be easy to be appalled by the errors and incidents that happened, but that must be countered by remembering how many patients and procedures are dealt with each year. On a statistical level, the serious and sentinel events are a tiny part of the overall equation.

But that doesn't make the ones that make the report any less shocking.

Among this year's MidCentral report was the case of a child who died from poisoning after a feeding tube became dislodged so food and fluids went straight into their abdomen.

That was the most serious of the 15 events - down from 22 last year - and was down to a lack of knowledge and inadequate guidelines.

Nine of the 15 events were falls and many of them happened when patients were moving from their bed. Other cases included one where a swab was left inside a patient.

In any line of work mistakes are made. They can be down to human error, mechanical error or a breakdown in systems or communication.

The difference with the health sector is that it deals with life and death situations and people in varying states of wellness.

There are cases all over the country where people have died when they probably shouldn't have.

No matter how small the percentage, these people and their families are the ones who have been let down by the system.

The reporting of these events and making them public are important for accountability and transparency.

Any failing is, and should be, taken seriously. The report shows how vital it is to have robust training schedules and iron-cast procedures in place.

Hospitals and medical centres can never realistically be expected to have a 100 per cent success rate for all the patients and clients they deal with in a year, but that shouldn't stop a "perfect score" being the target.


Once again, the central plateau showed its power yesterday afternoon. Mt Tongariro fired a plume of ash into the sky. From a distance the eruption was spectacular and beautiful, but such incidents can cause major disruptions for motorists and travellers, let alone the people who live nearby. Thankfully, no one was harmed by yesterday's significant event.

Manawatu Standard