Nearly 100 patients died after "serious" incidents in public hospitals during the year to June 30, according to a report out today.

The Quality Improvement Committee (QIC), appointed by the Minister of Health, published its third annual compilation of "serious and sentinel events" reported by the country's district health boards.

It includes any event which causes, or has the potential to cause, serious lasting disability or death, not related to the natural course of the patient's illness or underlying condition.

Of the 308 serious incidents reports, 92 involved patient deaths, although they were not necessarily caused by the event, the QIC said.

It said the purpose of publicising the incidents was to build a picture of the health system and improve on ways to minimise patient risk, not to chastise organisations or individuals.

"From a clinical perspective, blame is counter-productive: it decreases willingness to report and it does not engage institutions to design the safest possible system of care; it incorrectly assumes that individuals are responsible for errors, and removing an individual but not fixing an incorrect process will not prevent future errors," the QIC said in a statement.

Health Ministry principal medical adviser David Galler said all deaths and injuries were a tragedy for families and of great concern to DHBs.

"However, the reality is that even with the best people, processes and systems, errors can occur.

"When they do, we need to find out what went wrong, whether it could have been prevented, and what improvements or changes should be made."

He said clinical management problems -- which include misdiagnosis and delayed or inadequate treatment -- made up 39 per cent of incidents, while falls constituted a further 27 per cent.

Dr Galler said during the same period more than 950,000 people visited New Zealand hospitals. This meant only three in 10,000 were affected.

"Most people are treated in our hospitals every year without adverse incident, but these findings show we need to do better. The challenge is to actively learn from our mistakes to improve frontline delivery of health care."

While this year's figures were higher than the 258 events in 2007/08, the committee said it was important to note this referred to reported events.

It said the number was expected to continue increasing as the reporting system was improved.

Hawke's Bay DHB chief executive Kevin Snee said it was important hospitals maintained their transparency.

"Any event highlighted a continuing need for improvement and the DHB was continually building on its strong quality and risk focus to develop a culture of patient safety."

- NZPA