A report by the Ministry of Health's Quality Improvement Committee (QIC) entitled: 'The Serious and Sentinel Events List' detailed 258 incidents, including 76 deaths in the year to June 2008.
This is a significant increase over the previous year when 182 incidents and 40 deaths were recorded. All of the events could've been avoided.
The list was drawn from 21 district health boards.
The Chairman of the QIC said that each case was preventable and the aim of the report was to prevent recurrences.
According to the NZ Herald
"In Auckland, all a paitent's teeth were removed, rather than just the scheduled several teeth, because a referral letter was scanned under the wrong patient's name.
In another Auckland incident, incorrect laboratory results showed a pregnant immigrant had TB, prompting the termination of the pregnancy.
The Hutt Valley DHB reported a case in which a patient terminated her pregnancy after it was wrongly identified as ectopic.
A Canterbury patient required a second operation to remove a surgical drape left inside her in the first operation.
There were several reports of anaesthetised patients falling from operating tables.
More than half (53 per cent) of the events associated with the death of a patient were a result of suicide, and there were several cases in which mismanaged births had contributed to the deaths of infants.
Canterbury reported 41 incidents, the highest number, followed by Waikato with 36, Auckland 30, Counties Manukau 23 and Southland with 18.
The rest ranged between 16 (Capital and Coast) and two (Wairarapa and Midcentral)."
Posts
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.