Lakes DHB reports 11 'serious adverse events'

Five people fracturing bones in falls, and four who suffered harm as the result of "clinical process" are among 11 medical mishaps reported by Lakes District Health Board in the year to June.

The health board, which covers Rotorua and Taupo hospitals, reported 11 serious adverse events, compared with nine the previous year.

It's prompted several changes - including a guide for American doctors on the different names of medicines in New Zealand, revised pre-treatment chemotherapy checks and recording of wound dressings at the end of surgery.

Five of the events were falls with harm, two were patients with medication-related events and four patients suffered harm as a result of clinical process.

However, no patients died as a result of the events, the health board said in a statement.

It would not release any further information on the incidents.

Nine of the events were at Rotorua Hospital and two at Taupo Hospital.

Lakes District Health Board quality, risk and clinical governance director Dr Sharon Kletchko would not clarify what incidents happened where, citing patient confidentiality.

Every year health boards report to their communities the serious adverse events that were declared to the Health Quality and Safety Commission during that year.

Serious adverse events are incidents resulting in a patient dying or suffering serious harm from using health and disability services.

Dr Kletchko said normal variation was expected in the number of incidents reported.

"This is considered expected normal variation - for example your grocery bill is probably similar each week but not identical."

Several improvements have come about as a result of the events. One was a guide explaining different medicine names in New Zealand compared with the US.

Dr Kletchko said another was changing the forms used in operating theatres to record the number of wound dressings applied at the end of surgery.

She said brightly coloured tourniquets were now used for finger or toe surgeries so they could be seen by patient and staff - "reducing the risk of accidental non-removal".

There had also been a process change in the pre-treatment checks in chemotherapy, the board said.

Nationally in 2015-16 there were 520 adverse events reported to the commission by health boards, and 154 by other providers.

Serious adverse events in Lakes District Health Board
• Five falls with harm
• Two patients with medication-related events
• Four patients suffered harm as a result of clinical process
• Nine events at Rotorua Hospital
• Two at Taupo Hospital