The case was discussed at the DHB's "morbidity and mortality grand round" - a secretive session of doctors held regularly at all hospitals to discuss mistakes - in July.
The DHBs report their adverse events to the Health Quality and Safety Commission, which said today there had been five fewer reported in 2015/16 than in the preceding year.
Non-DHB health care providers reported 154 adverse events.
The largest single category of DHB adverse events involved clinical management - 245 incidents - followed by falls causing serious harm, 237 incidents; with medication-related events, at 21 incidents, accounting for the third-greatest number.
Adverse events reported by the DHBs include:
Waitemata
• Delay in treatment of a patient with sepsis (serious infection).
• A patient suffered an airway after eating, and died.
Auckland
• A delay in delivering a baby by caesarean section contributed to its death.
• The wrong tooth was pulled from a dental patient.
• A swab wasn't removed, necessitating a second operation.
• The wrong patient was given an MRI scan
• A failed surgical abortion probably caused major fetal abnormality due to the medication used during the procedure. The outcome of the case is not clear in the DHB's report.
• Delayed treatment for spinal cord compression causing a patient to become paraplegic.
• Blindness occurred in a patient's eye due to delayed treatment for diabetic eye disease. A clerical error was blamed.
Waikato
• A patient with a tear within the walls of the aorta artery was misdiagnosed as having gastritis and died suddenly.
• The wrong side of a patient's spine was operated on, in a procedure to remove part of a spinal disc.
• Staff did not recognise the positive result for an antibiotic-resistant superbug in a post-stroke patient transferred from Australia. Three other patients caught the bug. Staff were unfamiliar with the acronym CRE, which stands for carbapenem-resistant enterobacteriaceae.
Counties Manukau
• A surgical wound drainage tube was discovered in a patient three years after surgery. It had caused repeated infections and remained undetected in the chest wall as it was not visible on x-ray or ultrasound.
• Two patients suffered vision loss due to delays in follow-up appointments that were blamed on short-staffing.
Bay of Plenty
• The wrong skin lesion was removed from an anaesthetised patient's leg.
Hawkes Bay
• A patient suffered loss of vision from delayed treatment.
Hutt Valley
• A dental patient had the incorrect tooth removed.
• A baby died in the uterus of an acutely ill mother. Senior doctors were found to have supervised junior medical staff inadequately.
Nelson Marlborough
• Nine cases were reported of visual loss following delays in follow-up or treatment caused by increasing demand not being matched by staff numbers.
Southern
• A chest abnormality found unexpectedly on an x-ray was reported to the referring doctor, but not to the chest clinic. The patient had cancer and died. "We have had a poorly integrated patient radiology reporting system and IT radiology imaging systems," the DHB said.
• Thirty patients suffered loss of vision. Two cases were linked to problems with follow-up appointments and work-load and the other 28 are under investigation.
