Medical errors 'should not have happened'

21:56, Nov 21 2012

A very sick baby died on the same day it was given the all-clear by Waikato Hospital, a new report shows.

And a patient who didn't receive follow-up treatment after a scan found lung nodules died of cancer two years later. The incidents were two of 23 adverse events reported by the Waikato District Health Board between July 1, 2011, and June 30, 2012, to the Health Quality & Safety Commission, which released its annual serious and sentinel events report yesterday.

The report showed the Waikato District Health Board had the fifth-highest number of avoidable events during the period but its lowest number since publication of events started in 2007.

A baby admitted to the emergency department with vomiting and diarrhoea was kept overnight but was discharged the next day because "the baby's condition was not recognised by staff as being so unwell". The baby died that same day.

Other events included a patient who required a second surgery after a medical device was left in their body following a surgical procedure; and a maternity case where a woman experienced delays in getting to theatre for a caesarean section after she was diagnosed with fetal distress upon admission. Her baby died two days later.

In total six deaths, including one suicide, were reported.


The Waikato board's chief medical adviser, Dr Tom Watson, said apologies had been made in each incident.

"I've personally met with most of them, or their families, to discuss what happened and what has been done to address it," he said.

"We do take these very seriously.

"Nobody comes to work to try and cause harm, but it's a complex environment and we are dealing with human beings that do make mistakes.

"And sometimes you find the system is not as robust as we'd like it to be."

He said the district health board had since improved its follow-up procedures to ensure cases like the man who later died of cancer because he wasn't followed up with, never happened again.

The medical device that was left in a patient had also now been added to surgical checklists.

"That was a completely new procedure with the medical device - it wasn't on the normal count list. Subsequently it's now included in all counts."

Nationally there were 360 events, with delays in treatment an "increasing trend" which resulted in people needing more treatment, losing function and sometimes death.

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

Commission chairman Professor Alan Merry said that while not all the events were preventable, "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."

Nationally 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 three the previous year.



A patient had to have follow-up surgery after a medical device was left behind during the first surgery.

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

An unwell baby who was discharged, later died the same day.

Delays in getting a woman in labour to theatre for a caesarean resulted in the baby dying two days later.

A patient was given medication that caused temporary deafness.

Waikato Times