Deaths in hospital analysed in report

Six serious and sentinel events in the Nelson Marlborough region in a year include two patient deaths, a serious medication error and three hip fractures as a result of falls.

The Health Quality & Safety Commission released its 2011-12 Serious and Sentinel Events report today.

A serious adverse event is one that leads to significant additional treatment, but is not life-threatening. A sentinel adverse event is life-threatening or has led to an unexpected death or major loss of function.

In Nelson Marlborough, one patient died as the result of a presumed hospital-acquired infection and an audit is ongoing into sterilisation practices.

The death of a patient in surgery is being investigated by the coroner, and a serious medication error that occurred three days prior to, but considered unlikely to have caused, the death of another patient, is also before the coroner.

NMDHB chief medical officer Heather McPherson said in releasing these events to the public, her thoughts were with the patients and families who had suffered through the quality of health care delivered.

"We are acknowledging that our district health board takes quality and safety issues in our hospitals very seriously.

"Every health care professional comes to work to make a positive difference in the lives of patients and strives to give the best possible patient care; however, errors do happen and have tragic and very serious consequences on all concerned."

The national report shows that delayed medical treatment in hospitals is an "increasing trend" and has resulted in people needing more treatment, losing function and sometimes death.

While the number of falls in hospitals had decreased, clinical management events, delayed treatment and in-patient suicides had increased.

The report included events district health boards considered to be serious in that they led to additional treatment or loss of function, or sentinel events which were life-threatening and-or led to an unexpected death.

Not all 360 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."

There were 111 clinical management events, up from 105 the previous year, and 17 cases of delayed treatment, which the report stated was an "increasing trend".

There were 18 medication errors, down from 25 the previous year, and 17 suspected in-patient suicides, up from the three the previous year.

The greater number of suspected suicides did not appear to be part of an increasing trend, Prof Merry said. Most involved mental health patients, but two were patients in general wards.

There were 170 falls, down 13 per cent from the previous year, and the first decrease since reporting began six years ago.

Falls represent 47 per cent of all serious and sentinel events reported for the 2011-12 year.

The total amount of events was down 3 per cent from the 2010-11 year, and while that was positive, Prof Merry said too many people were still being harmed while receiving health care.

"This is not about apportioning blame," he said.

"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."