KEY POINTS:
The landmark acknowledgement that preventable mistakes killed 40 public hospital patients in one year understates the problem and it may well be at least two years before a more reliable count can be made.
The Government-appointed Quality Improvement Committee yesterday released the first national tally of "serious and sentinel events" at district health boards, following requests by the Herald and other media for details of the harm to patients.
The responses of individual boards covering hundreds of cases over several years include the death of a newborn baby at Waikato Hospital after independent midwives allegedly failed to request medical help quickly enough, delayed cancer diagnosis at Auckland City Hospital, and the death of a Waitemata patient with low blood pressure after delayed diagnosis of a gastric ulcer.
The major, preventable events reported by the committee for the past financial year potentially or actually harmed 182 patients and included 40 deaths. They were among more than 834,000 patients treated at public hospitals that year.
Explaining the figures, which show Auckland DHB had the most events, at 26, officials said they could not be used to compare hospitals, because boards defined and reported events differently and cared for patient populations with varying degrees of complexity.
Committee head and Auckland board chairman Pat Snedden said the figures did not show his DHB was the worst.
"It has one-fifth of all hospital activity nationally and it has the highest complexity. It has advanced reporting systems ... and that contributes to your number of events."
He said it was hoped to have a standardised national system of reporting such events in place by July 2010.
Committee member Dr Mary Seddon, the clinical director of the Counties Manukau board's quality improvement unit, said there were more preventable incidents than had been included in the report.
"A number of sentinel and serious events are discussed at mortality and morbidity peer review meetings. That's done under privilege at our hospital and we haven't included those at this stage."
One draft of the report calculates there were 2.2 serious and sentinel events per 10,000 patients last year. This is about a tenth of the rate - 0.2 per cent - at which hospital patients were found, in a study led by Professor Peter Davis, to suffer a preventable mistake that resulted in death or permanent disability.
National Party health spokesman Tony Ryall said the committee's figures vastly understated the size of the problem.
"The Government has ignored repeated calls to do this [create a national reporting system] because it didn't want the public to know the fact our frontline medical staff are so overloaded with bureaucracy that all these mistakes are happening."
Health Minister David Cunliffe disagreed and said New Zealand hospitals were among the safest in the world.
Professor Davis, the Prime Minister's husband, said better computer-based systems offered great gains in safety but too little progress was being made.
