Reported instances of harm in Southern District Health
Board hospitals are down 25%, a sign its hospitals have become
safer, the board says.
The figures do not reflect reduced reporting, it also said.
The 2011-12 "serious and sentinel" report shows Southern had
30 events, 10 fewer than last year.
There were six deaths, although these were not necessarily
because of the reported incident, and not all investigations
have been completed.
Southern had the third highest level of 20 health boards,
which in total reported 360 adverse events (including 91
Southern's report included the case of the woman who had an
unnecessary mastectomy in Dunedin. This was revealed as
happening after the mixing up of two biopsy specimens. That
incident, and those of a similar nature at other DHBs, led to
a national inquiry into pathology procedures.
Other cases in the report released yesterday included the
death of a person in Southland after CPR was not administered
because staff incorrectly assumed the patient had a "not for
A tumour identified as an incidental finding on a scan was
not followed up, leading to a tightening-up of procedures.
Delayed treatment of a maternity patient resulted in the
woman requiring resuscitation; a maternity specific early
warning score tool was being developed.
Another investigation was under way into a patient who had a
serious allergic antibiotic reaction despite a documented
An investigation was still under way into a missed cancer
diagnosis, one of several radiology-related incidents.
Patient services medical director Dick Bunton said he did not
believe Southern had a particular issue with radiology
services, although an anticipated information technology
upgrade should reduce the number of patients inadequately
Mr Bunton said people could infer from the drop in cases that
public hospitals in the South were becoming safer.
This was because of robust reporting systems, and a medical
culture that was less likely to hide mistakes.
Now in its sixth year, the report and other measures had
changed the culture from fearing criticism, to openly
reporting incidents, Mr Bunton said.
Mr Bunton said year-on-year comparisons were better than
comparing Southern with other boards.
Southern had a similar breakdown by incident type to the
national picture, which was reassuring.
He agreed the World Health Organisation surgical safety
checklist introduced a couple of years ago - "so simple but
effective" - was reducing harm from surgical mistakes.
Otago had 19 and Southland 11 of the cases, which was in line
with their populations, Mr Bunton said.
Health Quality and Safety Commission chairman Prof Alan Merry
welcomed a 3% drop nationally in serious and sentinel events.
Nearly half of all events were falls, but he was pleased
these had dropped this year, for the first time since
He was concerned by increasing instances of delayed treatment
due to failures in patient-management systems.
Boards reporting delayed treatment incidents had been asked
for more detail.
More suspected suicides of inpatients this year did not
appear to be a trend. Most, although not all, were mental
The commission wanted to increase the range of organisations
in future reports, and was in talks with various providers
about this. These included private hospitals, hospices,
ambulance, and care agencies.
Southern DHB serious and sentinel events by type:
• Clinical management 40%
• Falls 37%
• Medication error 10%
• Suspected inpatient suicide 7%
• Wrong patient, site, or procedure 3%
• Absent without leave/missing patient 3%