Search for health excellence

A single death of a patient in hospital, or under the care of a district health board, as a result of a preventable medical mishap is one death too many. The fact that last year - from July 1, 2010 to June 30, 2011 - there were 377 serious or sentinel events, including 86 deaths, reported throughout the country is undoubtedly cause for concern.

Questions should be asked as to how and why these occur - and what is to be done to make sure the causes, be they systematic or relating to human error, are as far as is possible eliminated.

The Serious and Sentinel Events Report was released on Monday by the Government's Health Quality and Safety Commission. It found falls were the most common event, with 195 recorded, up from 130 the previous year.

Other types of event included medication errors and clinical management incidents such as poor communication between health professionals, delayed diagnoses and delays in responding to patients' changing or deteriorating conditions.

There were also 11 cases of serious "wrong site surgery" - where surgery was performed on the wrong part of the body, the wrong procedure was performed, or the surgery was performed on the wrong patient.

New Zealand has 20 district health boards. The Southern District Health Board, formed through the amalgamation of the Otago and Southland boards in 2010, is the sixth biggest by population.

With 40 "events", 14 of which were sentinel - a sentinel event is deadly or life-threatening; a serious event is one that requires significant additional treatment - the SDHB had the fourth-highest tally in the country. Ahead of it was Auckland with 56, Waikato with 53, and Canterbury with 49.

Among the most significant examples recorded by the SDHB were those of a patient on a ventilation machine at home who died when power failed; a delay in resuscitating a patient in a ward; a death in a "remote site" because of delayed emergency treatment; and death from a burst aorta after discharge from an emergency department.

These and other similar examples were tragedies, all the more so because they were potentially avoidable; sympathy is naturally extended to the families of those bereaved as a result, and the SDHB is urged to learn whatever lessons can be taken from such events and incorporate them into best practice.

However, it is also important to place such events in a wider context. Broadly speaking, it is the same context that, against a background of finite funding, demands increasing resources be allocated to our health system by a rapidly ageing population, the evolution and advancement of medical science and technology, and the elevated - occasionally unrealistic - expectations of society.

Part of this is also the requirement for accountability and reporting of adverse events, as evidenced by this very report.

Life expectancy is significantly higher today than at any time in the past and continues to extend.

Medical procedures for the elderly are also on the increase, with some undertaken at ages that might have been unthinkable even a decade or two ago.

Increasing sophistication of medical techniques means that more difficult procedures are undertaken with increased frequency. Non-essential but transformative surgical procedures - countless knee and hip replacements for example - have ballooned.

And for the technologically literate generations of the late 20th and early 21st centuries, faith in medical intervention and practice is extraordinarily high. It is assumed by many that most medical situations can be diagnosed and successfully treated.

Many can be, of course, but no intervention is without risk. The challenge for those hospital staff and doctors charged with looking after their patients is to minimise risk and streamline procedures and manage systems so medical mishaps do not occur.

As the report indicates, New Zealand's health and disability system is some way from being perfect: there are isolated events which just should not happen.

The search for excellence must go on, but against this must be set the tensions that exist between ever-growing demand and finite medical resources, and the reality that however expert and careful are the doctors and staff, some small percentage of "accidents" are bound to happen.