KEY POINTS:
District health boards committed 182 serious mistakes involving patients in one year, a Government-appointed "quality improvement" committee will say today.
Some of the events involved the suicide of a psychiatric inpatient, an assault on a patient, a fall, and drug errors.
The Auckland board comes up worst, with 26 reported events, closely followed by Waikato on 24, then Waitemata and Canterbury with 22.
Officials will argue that this cannot be taken as proof that it is less safe than other boards, because of variations in reporting methods and since Auckland handles some of the country's most complex patients.
The report of the committee, headed by Auckland District Health Board chairman Pat Snedden, was obtained by the Herald yesterday, ahead of its official release tomorrow.
The committee has collated the first national statistics to coincide with the release of reports by individual boards in response to requests under the Official Information Act by the Herald for details of their "serious and sentinel events".
The committee's report follows Health and Disability Commissioner Ron Paterson's panning of health board safety last week when he addressed Parliament's health select committee.
He wants league tables created to rank hospitals nationally on measures such as drug errors, infections acquired in hospital and deaths during surgery.
Mr Snedden said last night that the figures represented 2.2 mistakes per 10,000 patients discharged - a small figure but one he described as "unacceptable".
"Behind every one of these figures is a story of a family that has been affected and harmed by some mistake in the health system."
Collating the "extraordinarily regrettable" mistakes was the first step toward measuring and improving the system, Mr Snedden said.
The report says 21 sentinel events and 52 serious events occurred at 12 health boards. Sentinel is defined as an event resulting in a patient's unanticipated death or permanent loss of function unrelated to the natural course of the patient's condition. Serious events have "the potential to result in significant harm".
The reported sentinel events at the 12 boards were one suicide, 16 clinical management problems, two drug errors, one fall and one assault.
For all 21 health boards, sentinel/serious events were reported for 0.022 per cent of hospital patients.
National Party health spokesman Tony Ryall predicted the quality committee report would be a sanitised version of the facts.
"To avoid facing the stark truth, the Ministry [of Health] will argue that the definitions used by each DHB vary and that this information is not complete."
Studies led by Auckland University medical researcher Professor Peter Davis, the Prime Minister's husband, have calculated from more than 6000 patient records that 13 per cent of hospital admissions involve an adverse event in hospital or the community; and 0.2 per cent are linked to a preventable event causing permanent disability or death.
The quality committee report warns that because hospitals vary in how they collate serious and sentinel events and the lack of a standardised definitions, the kind of league table wanted by Mr Paterson cannot yet be produced.
" ... it is not possible to make any valid comparison based on the number of incidents reported by different hospitals. The ... committee is looking to standardise the classification of serious and sentinel events in 2008."
The report also warns that using its data inappropriately "may adversely affect the culture of safety and openness that we are trying to build in DHBs. If clinicians experience the information being used against them or their DHB, then there may be less willingness to report."
The report says boards with higher numbers of reported events may simply have better reporting systems "and probably a superior safety culture".
GETTING IT WRONG
Serious reported mistakes involving patients, in the last financial year, by district health board:
* Auckland, 26
* Waitemata, 22
* Counties Manukau, 7
* Waikato, 24
* Northland, 6
* Lakes, 1
* Bay of Plenty, 1
* Capital and Coast, 14
* Canterbury, 22
Total for all 21, 182
EXAMPLES OF MISTAKES
* A patient died after incorrect prescription of another patient's diabetes medication.
* A patient had a melanoma removed, only for doctors to find the procedure had already been performed by a locum surgeon.
* A baby died after showing heart rate irregularities during labour. The umbilical cord was wrapped around the baby's neck.
* Surgery began on the wrong side of a patient and was spotted part-way through the operation.
* A patient received feeding fluid for her gut into her vein instead.
