77 patients harmed
Two baby deaths, and a patient who had a heart attack because a tube put into their body was misplaced. These are among the 77 ‘‘serious adverse events’’ that took place in Canterbury District Health Board (CDHB) facilities in the 12 months to June this year – more than any other health board in the country.
An ‘‘adverse event’’ is one where a patient needs significant extra treatment, suffers major loss of function, their life is endangered or, worse, they unexpectedly die.
The health board released its adverse events report last week. It detailed how one patient deteriorated while on a waiting list for spinal surgery. They ended up losing function, and surgery could not reverse it.
It noted 47 falls resulting in a fracture or head injury, and 14 pressure injuries suffered in hospitals.
The report also noted three babies who were born in a poor condition, including one with pneumonia caused by a nonsymptomatic infection.
According to a review summary, an epidural – where drugs are injected around the spinal
Dr Sue Nightingale, health board chief medical officer
cord for pain relief during childbirth – was inserted after a ‘‘significant’’ slowing of the baby’s heart rate. Further abnormal heartbeat readings were attributed to the epidural.
‘‘This . . . resulted in a delay in delivery,’’ the report said. The baby could not be resuscitated after it was born.
A fourth baby who was stillborn prompted all health board facilities to stop using a particular product to test for premature membrane rupture (water breaking).
Staff relied on the accuracy of the test over other factors, including the patient’s history of ruptured membranes, a review summary said. The clinical guidelines did not point out the potential for false results. Furthermore, incorrect information put on the patient board meant staff did not further investigate the possibility of ruptured membranes.
The report said the testing product was immediately withdrawn and the clinical guidelines were amended.
This year’s report was an improvement on the 82 serious adverse events during the 2017-18 year, which included someone losing an eye because of a delayed appointment, and a woman who suffered a sepsis infection after swabs were left in after a caesarean section.
Nationally, 916 adverse events were reported to the Health, Quality and Safety Commission by district health boards and other health providers for the 2018-19 year. Health board chief medical officer Dr Sue Nightingale said it aimed for ‘‘zero harm’’. A culture that encouraged staff to report events was vital to improving care, she said.
Changes that came out of the latest review included telling all patients waiting for spinal surgery about the risks, possible symptoms and actions they should take. A new pilot model reallocated theatre time to make room for more spinal surgery.
Nightingale said there had also been a 5 per cent reduction in falls resulting in injury per 1000 inpatient bed days, compared with the 2017-18 year.However, falls were still a major cause of bad outcomes.
General manager Olivier Lacoua hopes the restaurant, with 360-degree views, will become a dining destination.
A culture that encouraged staff to report events was vital to improving care.