After the baby's death, a new policy was devised for the use of Misoprostol and staff education was undertaken.
The case is among 377 public hospital mishaps in the year to last June outlined in a report released yesterday by the Health Quality and Safety Commission.
Eighty-six patients died.
Other mishaps revealed included:
* Another Waitemata DHB patient in labour was sent home for six hours after staff misread equipment that monitors fetal heart rates. The baby died.
* A Waikato DHB patient died when a heart pacemaker was accidently turned off.
* A Counties Manukau patient on home dialysis bled to death after blood lines were incorrectly connected.
* A critically ill patient died after taking medication intended for another patient due to a prescription mix-up.
* A patient died after a nurse administered the wrong drug dosage.
* A Southern DHB patient on a ventilator at home died because of a power failure.
* 11 patients had surgery on the wrong body part, got the wrong procedure or missed treatment altogether when their operation was performed on another person.
The Serious and Sentinel Events Report identified events which were life-threatening, led to an unexpected death, or to a major loss of function.
The number of incidents has increased - up from 318 the year before - and more than doubled in the five years from 2006-07.
Commission chairman Professor Alan Merry said that partly reflected an increase in the number of people falling down in hospital, and in incidents being reported.
However, he said the people involved in the 377 events were let down by a system that existed to protect them. "We should view these events through the eyes of patients and their families, and acknowledge that many of them should never have happened," he said.
In one surgical mishap, a patient had their digestive system treated - a procedure meant for another patient - because the name label was attached to the wrong person's form.
In another mix-up, surgery was carried out on the wrong patient because the biopsy results were confused.
"Each of these stories is about real people having things go wrong that shouldn't go wrong," said Professor Merry.
Falls were the most common events - 195, up from 130 the previous year.
Other incidents included errors of diagnosis and treatment, wrong medication or dosage, physical assaults and infections.
Eileen Anderson's family know first-hand the tragic effect of a hospital mishap.
Their mother was 91 when, in 2002, she was taken to Palmerston North Hospital with what appeared to be a respiratory tract infection.
However, a chart mix-up and lack of checking meant she was given another patient's medication for four days, leading to a rapid decline in her health.
Mrs Anderson's family were not called in time to get to her bedside before she died, said the report.
"We just wanted accountability," her daughter Helen is recorded in the report as saying, "and where doctors or nurses admitted their mistakes, we valued their honesty.
"The lack of openness and sensitivity led to a prolonged dispute that certainly took a heavy toll on us and on a good number of hospital staff as well."
Auckland DHB topped the list for medical mishaps in 2010-11, with 56 events, followed by Waikato (53) and Canterbury (49).
Professor Merry said this did not necessarily suggest those with higher totals were worse than the others.
Larger DHBs, such as Auckland, would have more incidents because they dealt with more patients and more-complex cases.
The commission said the variations could also signal that staff were safety focused and were actively reporting incidents.
While some adverse events were outside of the hospitals' control, many were preventable and "should never have happened".
The commission said NZ had an excellent health system. More than 2.7 million people were treated in public hospitals or as outpatients each year; very few came to harm.
Professor Merry said the report was not about apportioning blame. "It's about improving the quality and safety of our ... services."
Canterbury DHB chief David Meates agreed. "If we don't learn from our mistakes or near-misses, the system won't improve.
"We have developed a culture where we continue to make events visible so that we can continue to improve the standard and quality of care that we provide."
Were you involved in any such cases? Email newsdesk@nzherald.co.nz.
