Surgical swab left inside patient

A surgical swab left inside a patient and a patient who fell off the operating table were among incidents reported by the Southern District Health Board in the annual adverse events report, released yesterday.

The board reported 35 events in 2012-13, up five on last year. Nationally, there were 489 reported events - up from 360 - which for the first time included a number of non-DHB providers on a voluntary basis.

In 82 cases, patients died, but not necessarily because of the incident.

At the SDHB, six patients involved in adverse incidents died, but patient services medical director Dick Bunton stressed their deaths were not necessarily because of the event.

A swab was left inside a patient who underwent cardiac surgery, which was removed after it was identified in an X-ray, and the patient suffered no permanent effects, Mr Bunton said.

In another case, a patient was given an extra dose of anti-coagulant because of inadequate drug chart scrutiny.

The patient died, not necessarily because of the incident, but it might have contributed, Mr Bunton said.

In another case, a surgeon started to operate on a patient on the wrong side.

The surgeon made the skin incision, but realised the mistake and operated on the correct side.

An investigation found the patient was not marked pre-operatively to indicate the site.

''The open disclosure which occurred should attract positive attention as an example of good practice,'' a report on the incident said.

A patient who fell off the operating table during a hip fracture repair sustained bruising but no serious injury.

Other incidents included wrongly identifying a specimen in theatre; giving a baby the wrong breast milk; inadequate monitoring leading to cardio-pulmonary arrest; and wound infection following pacemaker insertion for three patients.

By type, clinical process faults at the SDHB accounted for the largest number of incidents, 40%, followed by falls (31%).

Mr Bunton said the report, now in its seventh year, had led to improved checking and other procedures, which in some areas could eliminate the chance of a mistake recurring.

However, there would always be adverse events because of human fallibility, he said.

The non-DHB entities reported 52 events, from a mix of private hospitals, rest-homes, hospices, disability services and primary health providers.


Sentinel events
2012-13: 35
: 489
2012-13: 360

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