Hospitals to blame in 92 deaths

BY RUTH HILL AND KATE NEWTON

Last updated 05:00 01/12/2009

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Hospital errors have been implicated in the deaths of 92 people in the past year – including a patient who died after staff forgot to switch on a heart monitor alarm.

Another patient died of blood poisoning, after picking up an infection in a hospital unit. A review found that equipment was not always cleaned between patients.

And one patient died of a heart condition while waiting too long for assessment in an emergency department.

The Health Ministry's third report of serious and sentinel events, made public yesterday, shows 308 patients suffered hospital mishaps or near-misses in the 2008–09 year – a rise of nearly 20 per cent on the previous year.

From a Waikato patient who had the wrong body part amputated to a Wellington patient who had a heart attack after being given the wrong medicine, many of the incidents were preventable, the report found.

Serious delays with Hutt Valley District Health Board's diagnostic services led to a backlog of more than 150 patients, of whom three so far have been found to have cancer.

One patient, who waited 26 days longer than maximum guidelines, has died.

Two others, who were supposed to be seen within three months, finally got their appointments after 6 1/2 months and nine months respectively.

Hutt Valley DHB acting chief executive Michael Hundleby said a review of waiting times – spurred by a clinician raising concerns – revealed "a cluster" of patients waiting too long.

Except for a small number of patients who cannot be tracked down, the backlog should be cleared by December 20.

An audit is under way in Otago after 26 GPs raised concerns that patients with suspected bowel cancer were waiting too long for tests.

Cancer Society spokeswoman Sarah Perry said there was "huge variation" in access to diagnostics nationwide.

"We'd hoped the development of the regional cancer networks would introduce consistency, but it hasn't made much difference yet."

Health Ministry medical adviser David Galler, an intensive care specialist at Middlemore Hospital, said the increase in sentinel events was mainly due to "better reporting" – but many still went unreported.

"It's safe to say this does not reflect the full extent of what's going on in hospitals ... But it's all about being honest with patients and their families about what's happened, and helping us to learn from our mistakes and engage with the public."

National and international studies suggest 10 to 15 per cent of hospital admissions are associated with medical errors, but half occur before the patient gets to hospital.

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Discussions were continuing with private hospitals and GP clinics to report their sentinel events too, Dr Galler said.

HOSPITAL HORRORS

* A Counties Manukau patient on a heart monitor died when staff did not check the patient's condition early enough, after the patient's identity was confused with that of another. An emergency team was called, but could not resuscitate the patient.

* Another Counties Manukau patient died after cross-infection between seven patients in one unit. The patient got sepsis – or blood poisoning – as a result of the infection and died.

* A Waikato patient died after a severe allergic reaction to medication. The patient's allergy and adverse reaction history was not checked by staff before the medication was administered.

* The wrong body was collected from Waikato Hospital's mortuary by a funeral director and the mistake was not discovered until the body was cremated. The hospital blamed the funeral director for the mixup but a review said the mortuary's collection guidelines were not widely available, resulting in confusion over who was responsible for identifying the body.

* A MidCentral patient died after the extent of the injuries they received in a car crash were not diagnosed. The patient arrived at hospital by ambulance, was assessed and discharged, but died five days later. An autopsy found the patient died as a direct result of their injuries.

* A Capital & Coast patient died when staff did not notice the patient had developed a life-threatening cardiac rhythm – because audible alarms on the patient's cardiac monitor had not been switched on.

* Another Capital & Coast patient went into cardiac arrest and had to be treated in ICU, after staff accidentally gave the patient a potentially dangerous medication that was stored next to the commonly used medicine the patient was meant to be given.

* An Otago patient died from blood poisoning after an abscess was incorrectly diagnosed as a sprain. The patient arrived at the emergency department by ambulance with hip pain and was seen in the middle of a busy shift before being discharged. The patient was brought back two days later, unconscious, and died despite surgery and intensive care.

* An Auckland patient died in the emergency department after a heart condition aorta was not diagnosed, after having to wait too long for assessment in a room staffed by a non-emergency nurse.

* A Hutt Valley patient with a severe physical disability died after her bowel was perforated during surgery to insert an abdominal feeding tube. The injury was not immediately diagnosed and she died from a resulting infection.

BY THE NUMBERS

There were 308 serious and sentinel events reported by district health boards between July 2008 and June 2009, including 92 deaths.

A sentinel adverse event is life-threatening, or has led to an unexpected death or permanent major disability. A serious adverse event leads to extra treatment but is not life-threatening.

WHAT THE REPORT FOUND:

* 3 in 10,000 patient admissions were associated with a sentinel or serious event.

* 65 per cent of incidents involved clinical management problems or falls.

* 37 patient suicides.

Capital & Coast 22 events, 8 deaths

* Hutt Valley 10 events, 3 deaths

* Wairarapa 2 events, 0 deaths

* MidCentral 8 events, 2 deaths

* Hawke's Bay 5 events, 3 deaths

* Whanganui 7 events, 6 deaths

* Taranaki 2 events, 0 deaths

* Tairawhiti 7 events, 6 deaths