23 Feb 2009

Serious mistakes at NZ hospitals revealed

8:10 pm on 23 February 2009

Shocking errors in New Zealand's hospitals have been detailed by a government-appointed committee charged with improving safety and quality in health.

The errors reported in the past year (2007-2008) are wide-ranging and include a laboratory mistake that led to an unnecessary termination of a pregnancy, and the unnecessary removal of a man's prostate gland.

Other mistakes include unnecessary operations, surgeries on the wrong part of a patient's body and suicides of mental health patients.

The Health Ministry's Quality Improvement Committee on Monday released details of 258 cases in which hospital patients were, or could have been, seriously harmed by preventable errors. They are termed "sentinel and serious events".

Seventy-six of those patients died not long after the mistakes - though not necessarily as a result.

The committee says nearly 900,000 people are treated and discharged each year and serious mistakes affect just three of every 10,000 patients.

However, the committee says mistakes cannot be tolerated, and it is releasing the information to help the health system become more open and accountable.

This is the second year details about errors that either harmed or could have harmed patients have been publicly issued. In the previous year, errors affected 182 patients, 40 of whom died.

Quality Improvement Committee chairperson Pat Snedden says the number of people caught up in serious mistakes in hospitals will continue to rise as health workers become more open in a bid to learn from and fix problems.

Mr Snedden says the health system has a moral duty to address its shortcomings.

Figures from all New Zealand's district health boards are on the Ministry of Health's website.


Two people in Northland died last year in what the district health board has defined as sentinel events.

One was a baby, stillborn with a cord prolapse, whose mother was transferred to Whangarei hospital too late to save the child.

The second was a mental health patient, who committed suicide, after what the DHB says was inadequate response to a GP referral and limited numbers of medical staff.

Northland Health staff also reported three other serious mistakes that did not lead to death - including a person suffering from tuberculosis who missed doses of treatment, became drug-resistant and suffered a relapse.

Hawkes Bay

In Hawkes Bay, there were four sentinel events and three serious events, compared with 12 events the previous year.

The sentinel events included the suicide of a mental health patient in the care of a medical ward and another patient in community care. Two of the serious events were medication errors.

DHB chief medical adviser David Grayson attributes a robust reporting system for the drop in the number of sentinel and serious events.


The number of hospital mistakes recorded in the Waikato region increased. Just over 384,000 patients were seen at the hospitals in the past year, with 36 incidents reported. In the previous year, 24 incidents were reported.

Nine patients died, including two babies, the suicide of a mental health patient, and a patient who waited in the emergency department for two hours and later died in intensive care.

Taranaki and Whanganui

In Taranaki, there were seven sentinel or serious events in the past year, compared with five in the previous year.

They included a patient with chest pains who was discharged from Taranaki Base Hospital in New Plymouth after a blood test. He died an hour later of a lung clot. Reviewers found there were enough signs that the patient should have been admitted.

Another person died from an allergic reaction to an antibiotic after staff failed to check their records which listed the patient's allergy.

In Whanganui, there were four sentinel or serious events in the past year, compared with three the previous year.

They included the case of a 23-year-old pregnant woman who was booked for outpatient follow-up after arriving at Whanganui hospital bleeding.

Her baby was born four days later and soon died. Reviewers again found she should have been admitted to hospital.


In Canterbury, the number of serious errors in hospitals doubled in the past year.

There were 41 incidents that either harmed, or could have harmed, patients in Canterbury, compared with 22 the previous year.

Canterbury DHB chief medical officer Nigel Millar says the rise is a challenge, but puts it down to an increase in the number of incidents being reported.


Otago District Health Board had seven sentinel or serious events in the past year.

In an administrative error, one patient was told her mammogram result was normal, when the screening had shown malignancy.

A prisoner receiving mental health treatment allegedly committed arson when on unauthorised leave, while another patient took an overdose of self-administered medication in a rehabilitation facility.

In another case, a surgical retractor was left in an abdominal wound.