Patient's bowel punctured by enema

CONCERNS: Five serious adverse events took place at Wairarapa Hospital in the 2012-13 year. PHOTO/FILE

A patient whose bowel was punctured accidentally and a baby who had septic arthritis which doctors didn't pick up on, are two of five muck-ups by Wairarapa medical staff.

Five serious adverse events (SAEs) resulting in serious harm to patients were reported to the Health Quality & Safety Commission by the Wairarapa district health board in the 2012-13 year.

In August last year, a patient went to the emergency department six days after having part of their colon removed and was prescribed an enema.

An hour later, the patient developed stomach pains and a scan showed the stitches from the previous surgery had ruptured after the tip of the enema had pierced the bowel.

Early investigation indicated the stitches were in the wrong place.

In another case, doctors delayed the diagnosis of a baby who had septic arthritis in its joints.

Earlier this year, one patient also suffered a chest injury when being transferred by ambulance from Wellington to Masterton.

Nationally, more than half of a total of 489 SAEs were caused by falls with 106 patients suffering hip injuries, including one patient in Wairarapa.

The patient had just had a hip replacement and got up to move when their feet got tangled in crutches, falling to the floor and fracturing their hip.

SAEs have increased by 21 per cent compared to last year but commission chairman Alan Merry, said the increase should be seen as an improvement in reporting methods used to identify them rather than an increase in the frequency of events.

"We expect increases in reported events to continue in the next few years as our reporting systems continue to improve," Professor Merry said.

Wairarapa had a low number of serious events compared with other small DHBs like West Coast, which reported 11 events, and South Canterbury which reported 17.

In the Wairarapa DHB's report breakdown, it said it always sought to learn from such incidents and improve safety.

"We consider one event is one too many, and apologise unreservedly to the patients and families involved.

"We acknowledge the distress and grief that result when things go wrong in healthcare."

Other adverse events reported nationwide included delays in treatment, concerns about the accuracy of diagnoses, inadequate patient monitoring in hospital, near misses and medication events.