Editorial: Robust systems can fail


Running a hospital is a challenging and complex business.

The pressure on medical staff to diagnose and treat patients correctly and in a timely fashion when there are limited health resources undoubtedly puts them under huge pressure.

Hospitals such as Tauranga make for easy targets but get it right most of the time.

But the stakes are incredibly high. Most of us can have a bad day at work and no one is physically hurt or dies as a result. But in a hospital lives are on the line and one mistake or a series of errors can have catastrophic consequences.

A case in point featured in yesterday's edition in which we revealed the Health and Disability Commissioner found a raft of mistakes at Tauranga Hospital led to the misdiagnosis of a patient who later died.

The commissioner found the health board failed to provide appropriate care for the patient and breached the Code of Health and Disability Services Consumers' Rights.

The 78-year-old woman went into hospital suffering vomiting, dehydration and a groin lump. But after mistakes and communication failures she suffered a cardiac arrest and later died.

The investigation found there were inadequate records, and inconsistent and flawed clinical handover processes.

I found it disturbing the woman's husband had to empty containers of her vomit because nurses were not available often enough, and that the patient was not reviewed for 27 hours, during which time her condition deteriorated. Imagine how extremely distressing this was.

Hospital staff involved failed this patient horribly and apologised.

Such grave mistakes are difficult to forgive and hospitals need to do better than this.

But doctors are human and every system, no matter how robust, can fail.

The health board has addressed concerns highlighted in the commissioner's report and made changes as a result.

This is an appropriate response.

Nothing will bring this woman back and all medical professionals and their employers can do is learn from mistakes in the hope they are not repeated.

It is important, however, health professionals are accountable for their actions if they repeat mistakes.

- Bay of Plenty Times

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