Health system not 'perfect'

Richard Bunton
Richard Bunton
Only a "slightly naive" person would expect to be 100% safe from mishaps in the healthcare system, Southern District Health Board (Otago) chief medical officer Richard Bunton says.

He was responding to Southern's tally of 40 serious or sentinel medical mishaps for 2010-11.

Yesterday, the Otago Daily Times reported Southern's tally included 14 sentinel (life-threatening or deadly) events, including the death of a patient in the community because a power failure stopped a ventilation machine.

Mr Bunton said the ventilation machine failure was never fully explained.

Testing it failed to determine why its alarm did not sound, which would have given the family of the patient, who had muscular dystrophy, sufficient warning.

The machine was found to have no problem, he said.

The serious and sentinel events report released on Monday by the Health Quality and Safety Commission said the ventilation machine had "working alarm systems".

Three back-up battery power stations were purchased to prevent a future occurrence.

Mr Bunton said the "human factor" in health meant there would always be mistakes.

Safety systems designed to protect patients only worked if clinicians recognised warning signs and triggered them.

While Southern's 40 events was eight fewer than the previous year, this was most likely due to the latest tally not counting outpatient suicides.

Now in its fifth year, the report had reached a point of "plateau" in the past couple of years after a "frightening increase" in incidents in the first two to three years.

In every profession or industry, practitioners made errors, Mr Bunton said.

"For people to expect 100% perfect care when they come to hospital is understandable but slightly naive."

Four cases involving errors or delays in radiology did not indicate a serious issue with radiological services; two of the four had been in Southland Hospital, he said.

Asked if any of the cases struck him as describing a particularly poor standard of care, he said there was "one or two", which he declined to identify.

The emphasis was on improving standards, rather than blaming people for their mistakes, he said.

Each one was an opportunity to improve standards of care, Mr Bunton said.

"I won't pretend there's [not] one or two cases [where] you might think 'yeah, well that's pretty unfortunate and yes, we really made a bad job there'."

eileen.goodwin@odt.co.nz

Add a Comment