43 patient mishaps at Waikato DHB
Workload pressures and ‘‘shift-related fatigue’’ contributed to the death of a baby at Waikato Hospital.
Circumstances relating to the baby’s death were included in the Waikato District Health Board’s serious adverse events report released on Friday.
The death was one of a series of mishaps at the DHB during the past financial year.
The report lists 43 adverse events from July 2016 to June 2017, as compared with 41 events recorded in 2015/16.
Serious events are broken down into four categories: patient falls, infections, pressure injuries and other clinical events.
Eighteen patients suffered serious harm after falling, with fractured thighbones the most common injury.
Six patients developed serious wound infections, while two patients suffered pressure injuries.
One of the pressure injuries related to a patient’s use of a medical brace.
The DHB report noted the patient wasn’t provided with written information about how to use the brace or its associated risks.
In September 2016, a baby died following a delayed caesarean section.
Following the death, the DHB moved elective C-sections to the hospital’s acute surgical suite.
The DHB has previously declined to detail the circumstances of the baby’s death, but the report found workload pressures and shift-related fatigue were contributing factors.
Staffing issues also contributed to difficulties in continuity of care.
The incident was one of 17 clinical events that resulted in significant harm.
Meanwhile, a patient with an infected toe had an ultrasound scan performed on the wrong limb by Waikato Hospital staff.
In another case, a patient undergoing surgery received an ‘‘unconsented’’ procedure.
An investigation found that during surgery, staff had to stop to stabilise the patient’s condition.
‘‘This may have resulted in a loss of concentration to both the surgeon and registrar,’’ the report said.
Staff are currently reviewing another case in which a swab was left in a patient’s vagina.