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Source: ONE News -
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Anyone watching the news this week about the report documenting the latest preventable hospital errors up and down the country could be forgiven for thinking the health system is going to hell in a handcart.
There were 76 deaths from avoidable medical mishaps in the 07/08 financial year .. thats up 90% on the first ever report last year. Including those deaths, there were 258 serious errors made &thats a 40% jump too. Ill admit some of those errors made disturbing reading.
There were the usual wrong-site surgery cases and broken hips from falling out of bed (or, in two cases, off the operating table). There was the patient too at one hospital who had a 30cm surgical drape left inside their body after an operation. And the patient who needed a few teeth extracted but ended up having them all whipped out my mistake after their bar-coded name was read wrong before the procedure. Another patient up north was misdiagnosed with a drug-resistant form of TB and deported before it was discovered the lab had botched up the result. And the tale of yet another who had come to the Emergency Department (ED) after an assault with a head injury and who went AWOL in the hospital, managing to prise a window open and jump 20 feet, landing injured on the ground below.
But I'd argue strongly that one needs to keep some perspective about these figures. The first fact is that 258 cases out of a total of 900,000 hospital patients nationwide is pretty small beer. I know that's cold comfort to you if the error occurred to you or one of your loved ones .. a fact the DHB Quality Improvement Committee was quick to point out. All 258 cases are a tragedy for patients from their perspective. But the fact remains that when its all added up, those rates translate into a serious error occurring in only 3 out of every 10,000 patients. Not that high is it?
And we have to remember that this exercise, getting DHBs and their staff to voluntarily fess up about their mistakes, is a positive one. Its aimed at reducing errors and harm by being upfront, admitting mistakes and learning from them. Lets face it, such blood-letting and honesty has to deliver public good doesnt it? And all hospitals have been at pains to put new measures in place to improve the patient journey though hospital and to cut those error rates down. Indeed .. being able to read about errors in other hospitals is good for them too &they can learn from the mistakes of their colleagues down country.
Let's take the case I featured in my story which aired on One News on Monday night. I used an example of a young woman who was raced to Christchurch hospitals Emergency Department last year after a car accident. I first ran her story after her family contacted me last year. Olivia Sherriff had x-rays taken on that fateful Friday night but her family was told to take her home the next morning. No-one read or recorded her x-ray results. They were flat out in ED that night admittedly, but an assumption was made by largely visual and verbal observations that her injuries were not all that serious.
Her mum Rhonda says Olivia spent the week-end in bed at home in a huge amount of pain. She took Olivia to the GP first thing Monday morning and he was immediately concerned and told Rhonda to take her daughter straight back to hospital. Rhonda says when they re-appeared back in ED they were met by a raft of nurses and doctors who put Olivia on a gurney, with one doctor apologising that he was sorry that they'd let her down. He had apparently just viewed her Friday night x-rays and seen straight away that she had broken ribs, a fractured pelvis, bruised lung and a rare skull fracture. Clearly she should never have been sent home in the first place.
Olivia has made a good recovery from her injuries and her treatment on her return to Christchurch hospital was first rate. But its the post-script to this tale which is the most heartening thing.
It turns out that after my story on Olivia went to air last year, Rhonda was contacted by Dr Nigel Millar, the top doctor at the DHB, and the head nurse Mary Gordon who took the time to visit the family and hear their concerns. Whats more, they offered Rhonda the opportunity to address their ED staff to share her concerns over her daughters care. This Rhonda duly did last November. She addressed a room full of 60 ED staff who all took time from their duties to come and hear her speak. They apparently asked pertinent questions and Rhonda was reassured that changes had been made to radiology and discharge rules in an effort to ensure such an incident did not happen again. Rhonda says she was heartened that they took the time to listen and act upon her concerns and she came away from that talk feeling that much good had come from it.
I understand the Health and Disability Commissioner has applauded the Canterbury DHB for how it quietly went about and handled this to try and right a wrong and learn from it. They never sought media attention for it either. I only heard about it from Rhonda last week.
A couple of questions still linger in my mind from Mondays preventable error report though.
Why were some DHB error rates, like Canterbury and Waikatos &.so much higher than others? Its no surprise that the bigger the hospital, the higher the error rates in one sense, because the most complex patients have a bigger risk of complication and they all go to the larger tertiary hospitals. But why did some other large DHBs have much lower error rates .. even lower than their rates the previous year? Is it because they made fewer mistakes and learned fast from the errors theyd admitted to in last years report? Could be. Or is it because fewer mistakes were reported? Who really knows or will ever know? Reporting is, after all, voluntary not mandatory. This fact of varying rates and figures between DHBs bothered Health and Disability Commissioner Ron Paterson in the interview I did with him. Canterbury with 41 errors topping the charts looked the worst on paper. Yet could it perhaps be that they are just the most diligent at fessing up and reporting their incidents?
