A surgical item not removed after an abdominal operation and a patient being wrongly told her screening mammogram was clear were among seven serious medical mistakes reported at the Otago District Health Board in the year to last June.
In one case a man died after taking an overdose of prescription medicines he had brought to a rehabilitation facility and was taking unbeknown to staff, but chief medical officer Richard Bunton said the death was not necessarily a result of taking those drugs.
The person concerned had other medical issues.
The investigation in that case did not reveal significant systems failures, gaps or risks that contributed to the incident.
Mr Bunton said it was difficult to say such an event could not happen again.
Although he would not identify where the incident occurred, it was not the type of facility where people were frisked or searched for drugs.
More than 70 people died as a result of serious and sentinel mistakes made in New Zealand public hospitals during the 12 months to June 2008, a report released yesterday showed.
The report revealed 258 patients were involved in medical mistakes and botch-ups nationally which either did, or could have, cost them their lives or caused serious harm.
Mr Bunton said Otago's number of sentinel and serious events was low, given the board had more than 30,000 inpatient discharges a year.
He was confident such events were being reported by staff.
Given the complexity of the work being done, it was unlikely there would come a time when there would be no serious events.
It was important people learned from them and that the same sorts of events were not recurring year after year.
Reports of events usually showed there was not one particular thing that went wrong but a series of things, not significant in themselves, but in retrospect the combination of which could be seen as significant.
The most powerful diagnostic equipment medicine had was "the retrospectoscope", he said.
In the abdominal surgery case, a surgical item used to protect the bowel was not removed and the patient had to undergo a second operation for this.
It had not compromised the patient clinically.
Mr Bunton said the item had not been included in the original count sheet.
Since the incident, the count sheet had been audited for accurate documentation.
A different version of this equipment with an attached string and plastic ring was being evaluated.
The case involving the screening mammogram occurred at the time when manual data entry was necessary because of technical problems with the radiology information system.
The incorrect code had been entered and the mammogram was pronounced clear.
A month later, the woman, who had symptoms of breast cancer, was found to have the disease after having a biopsy.
Mr Bunton said the woman was receiving ongoing treatment.
It was difficult to say whether the delay had significantly affected her prognosis.
As a result of this incident, procedures for report coding had been reviewed and patient files from the start of digital mammography were also reviewed.
No similar cases were found.
One of the incidents, which could have resulted in the loss of a limb, involved the delayed release of a tourniquet during surgery.
Mr Bunton said tourniquets were often used in orthopaedic surgery when a bloodless site was required.
In this instance, staff believed the tourniquet had been turned off, but it remained on.
Luckily, the patient did not come to any serious harm.
New machines had since been purchased that monitored the tourniquet on a time basis and extra staff training had been carried out.
Other events in which investigation is not yet complete include a patient in a mental health service who allegedly committed an arson while on unauthorised leave, concerns about the monitoring of a patient before a cardiac arrest, and suspected failure of intravenous infusion equipment.
Mr Bunton said the last of these three cases remained a mystery.
It involved a patient who was receiving pain relief through a self-operated pump following surgery.
The patient received too much medication, leading to a severe drop in blood pressure, which was successfully treated.
At a glance
What are serious and sentinel events?
A sentinel event causes death, major loss of function, or is life-threatening.
A serious event requires significant additional treatment but is not life-threatening.
Sentinel events in Otago:
Retention of surgical item during abdominal operation.
Mammogram result incorrectly reported as clear.
Drug overdose by patient taking prescription medicines he had brought into rehabilitation centre.
Sentinel investigations in Otago not completed:
Concern over clinical monitoring of patient before cardiac arrest.
Patient allegedly committed arson during unauthorised leave from mental health service.
Severe drop in blood pressure of patient after receiving too much pain-relief medication from self-operated equipment.
Serious events in Otago:
Delayed release of mechanically operated tourniquet during surgery.
