Falls top hospitals' patient mishaps list

File photo / NZ Herald

Falls were the leading cause of major preventable "adverse events" in public hospitals in the year to June.

More than one-third of the 374 public patients involved in a serious event in the year to June had falls, the Health Quality and Safety Commission said yesterday.

The commission, which collates the statistics, said that 127 people died from a "serious or sentinel" event in 2009/10, up from 92 the year before, when there were 308 events.

The chairman of the commission's interim board, Professor Alan Merry, said the increase in the number of reported events was expected.

It reflected improved reporting by district health boards and a greater awareness of health and safety processes by public hospital staff.

But the commission also said that although the events were traumatic and often tragic, their number was small in comparison to the 998,390 inpatients and day patients treated and discharged by hospitals for the year - only 0.037 per cent of patients suffered an event.

The commission defines serious or sentinel events as those that cause, or could cause serious lasting disability or death, are not related to the patient's illness, injury or underlying condition and could have been prevented.

Some health boards have taken simple steps such as reducing the height of beds for patients at risk of falls, which have again been identified as the leading cause of "serious and sentinel events" in public hospitals.

Falls, particularly for the elderly, can result in a broken hip and a downward health spiral ending in death.

Falls accounted for 34 per cent of the events in 2009/10, clinical management problems such as medication errors 33 per cent and suicides 17 per cent.

Suicides accounted for nearly half of the deaths.

Professor Merry said the rise in suicide numbers in the latest report - 64 inpatients and outpatients compared with 37 the year before - was partly attributable to its inclusion of deaths that occurred up to seven days after contact with mental health services, a longer period than before.

He said the fact that the same types of events continued to predominate in public hospitals strongly suggested the problem areas were primarilysystems.

The Canterbury District Health Board had the greatest number of reported events, 69, followed by Waikato with 52, the former Otago board with 39, Counties Manukau 38 and Auckland 32.


MEDICAL FAILURES

Auckland DHB - Baby taken from hospital without approval. Social worker had failed to identify risks in an adoption case.

Auckland - Patient died from meningococcal blood poisoning. Case wrongly thought at first to be viral, rather than bacterial. Patient left waiting too long, insufficient recordings were made of vital signs and treatment delayed.

Auckland - Wrong sperm was used for donor insemination because an unused sperm container had not been discarded and the label was not detected as being incorrect. No pregnancy resulted.

Auckland - "Grossly inadequate" ventilation of intensive care patient during an MRI scan. Subsequent death was unrelated.

Auckland - Mother with baby accidentally fell asleep in parent room, suffocating the baby. Breastfeeding chairs and "safe sleeping" signs have been installed.

Counties Manukau - Abdominal lacerations from protruding metal on a commode toilet chair. Patient required surgery. Old commode chairs fixed.

Counties Manukau - Baby died after delay in identifying fetal distress during labour. Systems errors subsequently rectified, including the fact that a fetal monitoring machine's alarm was switched off by automatic default without staff knowing.

Bay of Plenty - Patient inhaled stomach contents when anaesthetic given and subsequently died. Attributed to lack of communication leading to a naso-gastric tube not being inserted before the patient was anaesthetised.