'Increasing trend' in delayed hospital treatment
A child who died of sepsis after having an abdominal feeding tube reinserted was one of 91 people who died in New Zealand hospitals as the result of serious medical events, some preventable, in the past year, a new health report says.
Their deaths were the result of adverse events including medication errors, in-patient suicides and delayed treatment, which is an "increasing trend", the Health Quality & Safety Commission 2011/12 Serious and Sentinel Events report, released today, said.
Among those killed by an event was one child in the Mid-Central District Health Board district. The 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.
Another was a kidney patient who bled to death at a community treatment centre in South Auckland after an alarm system was not activated because there was only one phone line.
Other deaths in the Counties Manukau area included the suicide of a mental health patient and a baby who was stillborn after there was a delay in recognising and treating its mother's ruptured uterus.
Not all 360 adverse events in the year to June 30 were preventable, but "many involved errors that should not have happened", the commission's chair, 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."
Seventeen people experienced delays in being diagnosed with cancer or another serious illness, and another 17 in-patients committed suicide while in care.
While the number of falls in New Zealand hospitals had decreased, clinical management events, delayed treatment and in-patient suicides had increased.
The report included events the country's district health boards considered to be serious in that the patient needed significant additional treatment or experienced loss of function, or sentinel events which were life-threatening and/or led to a patient's unexpected death.
While there was a sharp increase in suicides - from three in the 2010/11 year to 17 this year, in-patient suicides were not viewed as an increasing trend.
Most of the 17 cases involved mental health patients but two were patients in general wards.
The number of in-patient suicides has varied over the last five years. Three been reported since July.
There were 111 clinical management events, up from 105 the previous year, and 18 medication errors, down from 25 the previous year.
Nine people had instruments or swabs left inside them and 10 people had the wrong procedure or treatment, possibly because there was a mix-up in patient information.
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 three per cent from the 2010/11 year, and while that was a positive step, 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. This SSE report contributes to that by stimulating discussion about adverse events and identifying areas for improvement."
This was the first year that the country's 20 dhbs were required to report all serious and sentinel events, not just those which were considered preventable.
The commission was working with a number of health and disability organisations, such as the Disability Support Network and Ambulance NZ and individual providers such as Mercy Hospital Dunedin, with the view that they will also provide serious and sentinel event reports in the future.
DEATHS AT DISTRICT HEALTH BOARDS
A kidney patient who bled to death at a community treatment centre in South Auckland after an alarm system was not activated because there was only one phone line.
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.
A patient who didn't get follow up treatment after a scan found lung nodules died of cancer two years later.
Capital and Coast
Ten people – including a newborn –died while under the care of Capital and Coast District Health Board in the past year. One person died when a blood clot in their lung was not diagnosed on a CT scan at Wellington Hospital.
Two Wairarapa patients died from medication errors and a CT scan was performed on the wrong patient. In one incident incorrect thrombolytic medication was prescribed and administered to a patient who subsequently died.
A baby died following an emergency caesarean and a mental health patient was killed after being hit by a car while running away from care.
One patient died after developing septicaemia, following inadequate recognition of their condition.
A baby died due to aspiration pneumonia caused by meconium, another patient died after post-operative complications and a young adult died unexpectedly after being admitted to the Intensive Care Unit