Healthcare mistakes prove fatal
Two patients died as a result of healthcare errors in Taranaki hospitals during the past year, a report shows.
Taranaki District Health Board recorded nine serious adverse events – unintended or unexpected incidents resulting in patient death or significant loss of function – between July 1, 2017, and June 30, 2018, including the two that were fatal, the report released by the Health Quality and Safety Commission says.
One person died from a brain bleed caused by a fall. This is the fourth year in a row that a death from a brain bleed caused by a fall has been on the Taranaki DHB’s adverse events list.
The second fatality involved a patient with reduced mobility and pain who died after developing a blood clot.
Since then nurses have received training on the signs and symptoms of deep vein thrombosis and pulmonary embolism, Taranaki DHB chief medical adviser Greg Simmons said in an emailed statement.
‘‘Nurses have also received training on rapid nursing assessment techniques designed to detect patients whose condition is deteriorating.’’
The other seven serious adverse events included a woman in maternity sustaining a significant bleed after delivery, the management of a pregnant woman exposed to an infectious disease, falls resulting in fractured hips, and a patient who sustained significant pressure injuries on both heels.
Nationally 631 adverse events were reported to the commission by district health boards and 351 by other providers.
On its website the Taranaki DHB sincerely apologised to the patients and families/wha¯nau and acknowledged the distress that occurs ‘‘when things go wrong in healthcare’’.
Simmons said brain bleeds cause a type of stroke.
‘‘Strokes are relatively common and, if large enough, generally not difficult to detect clinically. They can be confirmed by a CT scan. People on blood thinning medications who fall and suffer a head knock are more likely to bleed into the brain.’’
Five of the nine adverse events were as a result of falls.
Some falls are unpreventable, Simmons said.
‘‘There are a number of strategies available to minimise falls, including a routine process of assessing a patient for their risk of falling on admission to hospital and where that risk is significant we use a number of methods such as sensor clips, one-on-one observation of high fall risk patients and anti-slip socks worn by patients while
staying in hospital.’’
Health care is demanding and Taranaki DHB staff do an excellent job at providing very competent and professional care to improve the health of its patients, he said.
‘‘Over the past year 26,216 people have been admitted and cared for at Taranaki Base and Ha¯wera hospitals and the vast majority are treated without incident.
‘‘However, when things go wrong it can be distressing for everyone.’’
Taranaki DHB is a strong advocate of the adverse event reporting process, he said.
‘‘Our staff are supported to recognise, report and participate in the review of adverse events. While this can be challenging and difficult for those involved, disclosure is a professional and legal obligation and is an important part of patient-centred care.
‘‘The intention behind the Adverse Events Report is to encourage an open culture of reporting, to learn from what happened, put in place systems to reduce the risk of it happening again and make hospital care even safer.’’