Report details deaths at Wanganui hospital

Seven deaths were recorded by Whanganui District Health Board in the past year, according to the Health Quality and Safety Commission NZ.
The commission's annual report on serious and sentinel events at the country's hospitals was released yesterday.
Between July 1 2009 and July 1 this year Whanganui District Health Board recorded nine serious and sentinel events.
These included:
Four deaths by suicide of community mental health patients known to the service within seven days of their deaths.
Two deaths resulting from falls.
One death as a result of infection following a plasma exchange.
One incorrect referral process for surgical assessment.
One medication error.
A serious or sentinel event has, or has the potential to result in, serious lasting disability or death, not related to the natural course of the patient's illness or underlying condition.
Julie Patterson, WDHB chief executive, said the board and staff welcomed the annual report.
Mrs Patterson said the DHB had an open disclosure policy and actively encouraged staff to report any adverse event, or event that had the potential to cause harm.
"These events are traumatic for the patients involved and their families. It's also distressing for clinical staff," she said.
She said it was very important to review and learn from these events to reduce the likelihood of them happening in future.
"Priority has been given to achieving a culture where staff report incidents and near misses, because they know how important it is to learn from these incidents and how essential open disclosure is for patients, families and the community at large," Mrs Patterson said.
"All our staff are highly committed to patient safety and take a great interest in this report."
About a year ago the WDHB appointed Sandy Blake to head the patient safety and service quality division and it is Mrs Blake and her team who head investigations into any incident occurring within the hospital.
In a soon to be published interview with the Chronicle, Mrs Blake said the Wanganui community would always be the hospital's biggest judge "and whether they perceive our hospital to be a safe place to come to".
Meanwhile, Professor Alan Merry, chairman of the interim board of the commission, said the latest figures had shown NZ hospitals have a continuing focus on patient safety. Professor Merry said in the 2009/2010 year, DHBs treated and discharged close to one million people.
"Of these, 374 people were involved in a serious or sentinel event that was actually or potentially preventable. Of that number, 127 died during admission or shortly afterwards, though not necessarily as a result of the event. Half of these deaths occurred through suicide," he said.
The commission said the three most commonly reported serious and sentinel events were falls (34 per cent), clinical management problems (33 per cent) and suicides (17 per cent).
In the year before there were 308 reported events and 92 deaths, with falls, clinical management problems and suicides also the biggest categories.
Prof Merry said the increase in reported events was anticipated and it illustrated improved reporting processes in hospitals and a greater awareness of health and safety processes.
"International experience with event reporting shows that the process of increasing awareness often results in a rise in the number of events reported.
"It's encouraging that many DHBs and private hospitals are introducing specific programmes and changes to make real improvements in patient safety."
These national changes include:
Most DHBs, and a number of private hospitals, have adopted the World Health Organisation's safe surgery checklist.
Many DHBs have instituted or improved comprehensive falls prevention programmes
Booking and referral processes have been improved.
A standardised medication chart is about to be introduced throughout NZ to reduce medication errors related to adult inpatients.
A standardised process to reconcile medicines and reduce medication errors at the point of handover of patient care is planned for all DHBs and has already been adopted by some, and by some private hospitals.
Wanganui's DHB has adopted all five national changes.
Prof Merry said NZ had an excellent health system by international standards and the vast majority of patients are treated safely and effectively.