No saving pair: Wairarapa Hospital

INCREASE: Wairarapa Hospital had seven serious and sentinel events in the 2013/14 year, up three from the last period. PHOTO/LYNDA FERINGA

Nothing more could have been done to save two patients who died unexpectedly in Wairarapa Hospital's care, says its chief medical officer, despite safety reviews finding concerns around clinical processes and delays in diagnoses.

The deaths, harm caused to three others and concerns around the high-dependency unit and sterilisation department, have driven the number of serious and sentinel events at the hospital to an all-time high since Health Quality and Safety Commission records began in 2006.

Its latest report shows one patient was given the wrong medication, one had a piece of plastic left in their bodies and another fell and broke a hip.

One person died in theatre after a post-operative bleed. A review found the initial surgery went smoothly but the patient had deteriorated.

Because of co-existing medical problems and a rare post-operative complication, the patient's deterioration wasn't picked up straightaway.

Wairarapa and Hutt Valley DHBs chief medical officer Iwona Stolarek said there was nothing staff could do.

"This case had incredibly rare complications, even our external reviewers thought it wouldn't have happened," Dr Stolarek said.

Another patient died while being transferred to another hospital - Wairarapa does not have an intensive-care unit.

A review found poor documentation, lack of awareness of technical preparation for transfers and a delay in diagnosis.

"This patient was very unwell even before they came to the hospital, we had very little hope they would survive the event," said Dr Stolarek.

"There were some things that might have changed the outcome had the person arrived in a different state."

She said staff were now more prepared to deal with similar situations.

A review of a patient who became unstable after being injected with the wrong medication found there were unlabelled and identical syringes.

Dr Stolarek said it was a concern and a policy around administering medication was being updated.

"We are not quite sure why that slipped that day.

"Good practice dictates we should label everything, we had a policy for everybody other than medical staff."

A piece of plastic which broke off during surgery and got stuck inside a patient, remains in the person's body. Staff decided the risk of harm in trying to find the plastic was greater than leaving it there. Nationwide, there was an increase in events.

Hutt Valley and Wairarapa DHBs general manager, quality and risk, Amber O'Callaghan said more people were reporting them. "It's probably an increase in the culture of reporting rather than an increase in actual events."

Dr Stolarek said it was a good sign and helped improve systems and processes.

"We don't want people to make the same mistakes."

The NZ Nurses Organisation said the increase was a symptom of an under-resourced health sector and overworked staff, not solely better reporting.

Dr Stolarek said it depended on the circumstances of each case.

Ms O'Callaghan said each event was thoroughly reviewed to minimise the risk of a repeat.