KEY POINTS:
Adverse events in the country's hospitals last year included patients falling from operating tables, a surgical drape left inside a patient after surgery and all of a patient's teeth being mistakenly removed.
The Serious and Sentinel Events list, released by the Ministry of Health's Quality Improvement Committee (QIC) today, comprised of 258 incidents, including 76 deaths, in the year ended June 2008, Auckland District Health Board and QIC chairman Patrick Snedden said.
Each of the 258 cases was preventable and the aim of the report was to prevent recurrences, he said.
"Over the same period, nearly 900,000 people were treated and discharged by our hospital staff," he said.
Last year, 182 events, including 40 deaths, were listed.
The list of serious and sentinel adverse incidents was compiled from the 21 district health boards (DHBs).
A sentinel adverse event is one that is life threatening or has led to an unanticipated death or major loss of function not related to the patient's illness.
A serious adverse event has the potential to result in death or major loss of function not related to the patient's illness.
Committee member Professor Alan Merry said he encouraged doctors to look not just at the statistics, but at the specific cases where incisions were made in the wrong places, swabs were left behind and the wrong operations were performed.
In Auckland, all a patient's teeth were removed, rather than just the scheduled several teeth, because a referral letter was scanned under the wrong patient's name.
In another Auckland incident, incorrect laboratory results showed a pregnant immigrant had TB, prompting the termination of the pregnancy.
The Hutt Valley DHB reported a case in which a patient terminated her pregnancy after it was wrongly identified as ectopic.
A Canterbury patient required a second operation to remove a surgical drape left inside her in the first operation.
There were several reports of anaesthetised patients falling from operating tables.
More than half (53 per cent) of the events associated with the death of a patient were a result of suicide, and there were several cases in which mismanaged births had contributed to the deaths of infants.
Canterbury reported 41 incidents, the highest number, followed by Waikato with 36, Auckland 30, Counties Manukau 23 and Southland with 18.
The rest ranged between 16 (Capital and Coast) and two (Wairarapa and Midcentral).
Dr Snedden said the purpose of the report was not to name and shame those involved with the incidents.
"Voluntary reporting by clinicians is essential if we are to learn from our mistakes," he said.
"It is not an easy or comfortable process for anyone who is involved in a situation where something has gone wrong, and it takes the right sort of environment to help make reporting easier."
- NZPA
