'Serious medical events' claim six lives

GWYNETH HYNDMAN
Last updated 12:11 21/11/2012

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There were 30 serious and sentinel events, which included errors, in Southern District Health Board hospitals during the 2011/12 year, six of which resulted in deaths.

A serious event is one that has led to significant additional treatment and a sentinel event is life-threatening or has led to an unexpected death or major loss of function.

The Health Quality and Safety Commission has this morning released its report of serious and sentinel events in district health board hospitals for the 2011/12 year.

The report says the 30 events in the Southern District Health Board area was down from 40 the previous year.

Twelve of the 30 serious and sentinel events were the result of clinical management errors, the report says.

One of the 30 incidents was from ''wrong site, wrong procedure or wrong patient'', while 11 of the events were from falls, the report says.

Nationally, the overall number for all 20 health boards has dropped to 360, down from 370 in the previous year, though the number of deaths have increased.

Ninety-one patients died, up from 86 in 2010/11, though not necessarily as a result of the adverse event which occurred, the report says.

Adverse events this last year include 170 falls, 111 clinical management events, 18 medication errors and 17 suspected in-patient suicides.

Commission chair Professor Alan Merry said not all the events described in the report were preventable, but many involved errors that should not have happened.

''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.''

The overall decrease in events - specifically falls - was good news he said, though there had been an increase in the number of cases of delayed treatment.

Commission reportable events clinical lead Dr David Sage said the cases involving delays emphasised two things: how important it was for clinicians to follow up when tests have been ordered, referrals made, or further treatment recommended; and the importance of formal reconciliation procedures when ordering biopsies and appointments.

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