• "Delay in baby's birth following signs of deterioration during labour increased risk of brain damage."
An adverse event is an incident that caused serious harm or death, or could have done so.
Of the 525 patients who suffered an adverse event at a DHB provider, 73 died, but the commission says these deaths were not necessarily a result of the adverse event.
The Auckland DHB reported the most adverse events, 96, followed by Counties Manukau on 69, Canterbury, 59, Waitemata, 53, and Waikato, 52. These are the DHBs with the larger populations and/or numbers of patients.
"In general, the number of adverse events occurring in each DHB is proportionate to the population each DHB serves," the commission says.
Falls were, as always, the greatest number of adverse events, with 277 cases. Clinical management was second highest, with 205 cases, arising from factors including delayed diagnosis or treatment, failure to remove surgical equipment before suturing up, doing the wrong procedure, pressure injuries, and failures in assessment and diagnosis.
Twenty-three medication mistakes were reported.
The non-DHB events included 43 at private surgical hospitals, nine in ambulance services, five in aged residential care facilities, four in primary care, one in the Defence Force and one in the Breast Screening Unit.
Mental health and addiction services are not covered by the report.
The commission says the increase in the number of adverse events reported by DHBs is "most likely a result of the health sector's commitment to reporting, and the improved systems it has developed."
DHBs must report adverse events to the commission. Many non-DHB providers do so voluntarily.
Commission chairman Professor Alan Merry says the 2014/15 report includes a special focus on learning from cases where there has been a delay in recognition or a lack of recognition of a patient's deteriorating condition.
'Deterioration can happen at any time in a patient's illness, but patients are especially vulnerable after surgery and when they are recovering from a very serious illness. Recognising and responding to this deterioration quickly is important to avoid cardiac arrest or admission to an intensive care unit."
The commission says New Zealand's adverse event levels are broadly comparable to Australia and Britain.
"The standard of health care in New Zealand is generally high, and most people are treated safely and without incident. However, a small number of people are harmed while they receive care."
