Rotorua Hospital staff errors have been linked to the deaths of five patients.
A further three patients have suffered adverse effects due to mismanagement.
The incidents, between July 2004 and June last year, included botched brain surgery, sexual assaults, and poor communication between staff resulting in death.
They are included in a report by the Quality Improvement Committee into mistakes made by the country's 21 district health boards.
The report includes 40 people who died New Zealand-wide.
Rotorua Hospital acknowledges the incidents were distressing for patients and their families as well as staff. They have led to improvements to health services and tighter monitoring of patients.
Lakes District Health Board communications officer Sue Wilkie said any adverse event was "one too many" and staff recognised it always caused distress and could lead to disability or death.
Recognising such events gave staff an opportunity to fully investigate and reduce the risk of problems re-occurring.
Three of the adverse events involving Lakes District Health Board resulted in complaints and investigations by the Health and Disability Commissioner. Of those, one went to mediation, one resulted in Lakes being found in breach and the other was still being investigated, Ms Wilkie said.
The Quality Improvement Committee was set up last year to provide independent advice to Parliament on ways to improve health services. It found in 2006/07, 182 patients in New Zealand hospitals were involved in actual or potentially preventable clinical incidents that resulted, or could have, in serious harm or death. Of those, 40 people died. Incidents at Rotorua Hospital in the past three years include the unexpected deaths of two patients, both suffering from the sleep disorder sleep apnoea. One died following surgery. Due to a lack of intensive care unit beds, the patient had to be nursed in a general ward where signs of their deteriorating condition were not recognised by nurses.
The second patient died at Rotorua Hospital before they could be assessed at another district health board. A review found the delivery of health services was inadequate and communication between the health boards was poor. In another case a patient died due to delays in referring them from Rotorua Hospital to "tertiary level" care. A review found "clerical" error was to blame, prompting the hospital to educate clerical staff on clinical processes.
Meanwhile, a "systems" error at Rotorua Hospital led to a patient having surgery on the wrong side of their brain in Auckland. The patient suffered no adverse effects.
The correct surgery was eventually performed but a review highlighted a need for better monitoring of National Health Index numbers so correct records are transferred with patients.
A patient, believed to be a mental health patient, committed suicide after leaving the hospital of their own accord. The health board built a fence around the inpatient garden area.
The mother of a patient who died at Rotorua Hospital two years ago says the incidents in the report "barely scratch the surface". Her daughter's death was investigated by the Health and Disability Commission which found no clinical error on the hospital's part.
However, it criticised the board for poor communication and ordered it apologise to the family. The mother, who doesn't want to be named, says she has met families of patients who have died or suffered adverse health effects as a result of clinical error.
"People are dying who shouldn't be dying and that's not good enough."
Health minister David Cunliffe has welcomed the report, saying transparency is the best way for the health sector to improve.
Rotorua Hospital staff errors have been linked to the deaths of five patients.
A further three patients have suffered adverse effects due to mismanagement.
The incidents, between July 2004 and June last year, included botched brain surgery, sexual assaults, and poor communication between staff resulting in death.
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