Patient hurt during staff arm wrestle

Whangarei Hospital.

ARM wrestling and other contact sports have been banned at Whangarei Hospital after a patient's arm was broken during a contest of strength with a staff member.

It is one of the more bizarre mishaps leading to a patient being injured while in the care of the Northland District Health Board in the last year, according to a new report called "Learning from Adverse Events". The patient, who had challenged the staff member to the match, ended up with a fractured upper arm.

The Health Quality and Safety Commission's report states there were 18 incidents of harm related to patients' care at Northland District Health Board facilities in the year from June 2014 to June 2015. The year before, there were 16, reflecting a year-on-year rise since what was then called Serious and Sentinel Events reporting began in 2006-07.

DHB chief executive Nick Chamberlain said the organisation is committed to providing safe, high-quality care - and reporting.

"We want Northland DHB to be a safe place for patients to come to. Everybody should speak up," Dr Chamberlain said.

There were no "sentinel" events - those resulting in death or serious physical or psychological injury - in Northland.

Falls accounted for eight of the 18 (seven in Whangarei and one in Dargaville hospitals), one less than last year. Nationwide, falls made up over half of all reports.

"While it is impossible to completely avoid falls, we continue to introduce interventions that will both reduce the rate of falls and the seriousness of harm to patients," Dr Chamberlain said.

A specialist reporting system has improved recording, sharing information and feedback about events, he said. The Reportable Events Committee reviews them and follows up on recommendations.

"Patient safety walk rounds", conducted by senior staff in clinical areas twice a month, also enable safety issues to be raised and fixed.

Nationally, the adverse events picture looks grim, with 525 patients affected in the year. Some resulted in death or permanent disability.

They also included a pocket knife hitting a Counties Manukau patient in the eye when a powerful magnetic resonance scan sucked the knife out of his pants "at speed". The blow tore the patient's retina and fractured the eye socket. The Counties Manukau DHB has installed a metal detector and has all MRI patients change into hospital gowns. At the Hutt Valley DHB, a dental therapist extracted the wrong tooth after looking at an X-ray the wrong way around, and, also at Hutt Valley, a patient has reduced renal function after his large rather than the smaller kidney was removed for a live-donor transplant.

But the "Learning" report reflects a culture shift toward transparency as well as the sector understanding how to avoid harmful events, the commission's chairman Professor Alan Merry said.