Mistakes contribute to 92 deaths in hospitals

Medical mistakes such as delayed diagnoses and incorrect treatment contributed to 92 deaths in New Zealand hospitals last year.

The third annual Serious and Sentinel Events Reported by District Health Boards report released today showed 308 people treated in New Zealand hospitals were involved in potentially preventable serious or sentinel events, up from 258 the year before.

According to the Health Ministry, a serious or sentinel event has, or has the potential to result in, serious lasting disability or death, not related to the natural course of the patient's illness or underlying condition.

Ninety-two people died during the admission or shortly afterwards, "though not necessarily as a result of the event", the report said.

Health Ministry principal medical advisor Dr David Galler, an intensive care specialist, said that even with the best people and practices, it was inevitable that such events would occur.

"When they do, we need to find out what went wrong, whether it could have been prevented, and what improvements or changes should be made," he said.

"Clinical management problems such as events or complications associated with diagnosis or delayed or inadequate treatment made up 39 percent of events and falls 27 percent."

Over the same period more than 950,000 people were treated and discharged from New Zealand hospitals.

"Most people are treated in our hospitals every year without adverse incident, but these findings show we need to do better. The challenge is to actively learn from our mistakes to improve frontline delivery of health care.

Dr Galler said it was critical they were open and transparent about mishaps in order to improve systems and processes,

The Ministry said the number of reported events was expected due to better reporting systems being put in place.

The figures show that only 0.09 percent of total admissions to DHBs involved a potentially preventable serious or sentinel event.

The majority of events (123 patients or 39 percent) were the result of a clinical management problem where there was a serious deterioration in a patient's condition that was not due to the natural course of their illness, or differs from the expected outcome of treatment.

The second largest category of events (85 patients or 27 percent) was falls which occurred when the patient was medically unwell and/or when an elderly patient was moving without assistance. 

The third largest category of events (39 patients or 12 percent) was suicide.

Waikato DHB had the highest number of events, (60) followed by Canterbury (44), Auckland (31) and Counties Manukau (29).

West Coast and Wairarapa and Taranaki had the fewest (2 each).

However, the report pointed out that differences could be due to differences in the way the incidents were reported rather than necessarily more events.

- © Fairfax NZ News