Ten errors a week in hospitals

A patient going blind after delays in care, undiagnosed tumours and a person dying after being discharged from hospital following a car crash were among almost 550 serious medical blunders across New Zealand in the past year.

Other patients endured the heartbreak of stillbirth, had cancerous tumours missed and suffered broken limbs after needless falls.

Some 542 adverse events – unintended or unexpected events that result in a patient being harmed – were recorded by district health boards in 2016-17, up slightly on the 520 the previous year.

In those 542 events, 79 people died, although not necessarily because of the mistake.

The Health Quality and Safety Commission, which released the report, said it reflected a ‘‘steady improvement … towards increased transparency and taking action based on learnings from system failings’’.

Twenty health boards outlined individuals cases to the commission, though with varying degrees of detail.

Among the adverse events disclosed were:

“Nine patients between the ages of 50 and 93 suffering harmful falls, including a bleed to the brain, a dislocation and fractured limbs (Northland).

“A delay following treatment for haemorrhoids leading to the late discovery of a rectal tumour (Northland).

“A delayed follow-up for treatment of the eye problem macular degeneration that left a patient blind (Northland).

“Six patients treated by the West Coast DHB had falls that left them with fractures, including to the knee, face and hip.

Canterbury DHB had 73 adverse events identified as serious, a marked rise on the 43 last year, with 29 patients suffering falls while in hospital – accounting for the largest proportion of its major medical errors.

The Canterbury DHB refused to give details of individual events, but said 20 patients also developed unnecessary pressure injuries while in hospital, the first time such injuries have been reported among its serious events.

Of the 542 adverse events, the majority related to clinical management events, the commission said.

Serious failings also led to falls, pressure injuries and healthcare associated infections.

Professor Alan Merry, the commission’s chairman, said the report reflected a ‘‘commitment to transparency, active engagement in learning opportunities and sharing of lessons learnt’’.