Medical mistakes take big leap up

18 serious mistakes including three deaths

ISOBEL EWING
Last updated 08:40 22/11/2012
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TARANAKI DAILY NEWS
Taranaki DHB Medical Officer of Health Dr Greg Simmons

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A dramatic jump in serious medical incidents reported by Taranaki's health authorities this year is the largest of any region in the country.

Taranaki Base Hospital recorded 18 serious mistakes this year, including three deaths, compared to just three mistakes last year.

Taranaki's three deaths were a brain injury victim delayed in transfer from Hawera hospital to Taranaki Base Hospital, a patient sent away from the Emergency Department on three occasions, and the suicide of a mental health inpatient discharged on leave.

The errors were outlined yesterday in the national Health Quality Improvement Committee's report Sentinel and Serious Events in New Zealand Hospitals 2011-12.

The Taranaki District Health Board said the reason for the rise is that Taranaki has finally caught up with the reporting method used by the rest of the country.

Dr David Sage of the Health Quality and Safety Commission said previously some DHBs were reporting all serious cases while others, including Taranaki, were reporting only serious cases they considered preventable.

He said the reporting requirements had been standardised so the new report contained all serious cases, including some that were preventable.

"Taranaki were only reporting preventable [cases], others were reporting a mixture.

"We've brought them all into line."

Taranaki DHB Medical Officer of Health Dr Greg Simmons said the move to report incidents that were not preventable explained a number of the mistakes.

Of the six serious falls that occurred, including two in which patients wearing their socks slipped on lino, some could not be prevented, he said.

"A lot of the falls people just keel over; you can't have a nurse there all the time."

He said although the rise in serious cases was not acceptable, the new report was an indication of how the culture of reporting of incidents was improving.

"Some were system errors, and unfortunately to err is human, but we try to keep it to a minimum.

"Robust reporting allows for better prevention and looking into events to prevent recurrence.

Dr Sage said this was the first year of full voluntary reporting from the public health sector and the committee was very pleased with the openness demonstrated.

Over the next two to three years the committee planned to extend the voluntary reporting of mistakes to the majority of the health sector, he said.

Taranaki's 18 cases were among 360 reported across the country for the 2011-12 year, down 3 per cent from 370 last year.

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In the 2011-12 year Taranaki Base Hospital had 100,652 outpatient visits, 27,180 inpatient visits and 46,665 Emergency Department visits.

DEATHS REPORTED

BY DISTRICT HEALTH BOARDS Counties Manukau: A kidney patient who bled to death at a community treatment centre after an alarm system was not activated because there was only one phone line.

Mid Central: A child died of sepsis after an abdominal feeding tube was reinserted, which resulted in food and/or fluid being released into their peritoneum, the tissue which lines the abdominal wall.

Waikato: A patient who didn't get follow-up treatment after a scan found lung nodules died of cancer two years later.

Capital and Coast: One person died when a blood clot in a lung was not diagnosed on a CT scan at Wellington Hospital.

Wairarapa: Two Wairarapa patients died from medication errors and a CT scan was performed on the wrong patient.

- Taranaki Daily News

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