A record-equalling number of reported medical mishaps in the Southern DHB area over the past year included the death of a new-born baby after delays in transferring them from their remote rural birthplace to specialist care.
Other incidents included three other deaths, two patients left paralysed, and a big rise in pressure injuries.
All health providers report serious adverse events - something which happened to someone while in healthcare which resulted in injury or death - to the Health Quality and Safety Commission, which released its annual review yesterday.
Comparing results year to year does not necessarily give a true picture as the system, intended to encourage reporting of issues so that lessons are learned and systems improved, relies on issues being raised.
However, the 66 events in the SDHB in 2019-20 matched the previous high in 2017-18.
Accident or mistake was rare and nothing in the report should deter people from seeking health care, the SDHB says.
"These events represent a tiny proportion of the many thousands of admissions, out-patient appointments and similar," chief medical officer Nigel Millar said.
"We recognise that when people are hurt or injured in our care it has a huge impact on the person involved and their whanau, family and friends.
"While we cannot turn the clock back and reverse what has happened, we can take action and implement changes to prevent such events occurring in the future."
The SDHB only releases minimal details of adverse events, so as not to identify patients or staff, or if other legal processes are still to be completed.
Covid-19 lockdown was a significant contributing factor in some incidents however, including a fall when staff were sent to cover in the Emergency Department meaning only three nurses were on hand to care for 28 patients, a delayed cancer diagnosis, and the death of a baby when pandemic restrictions meant the patient could not readily consult her partner.
The stress the DHB’s busy emergency departments are under was also a regular theme, and contributed to incidents such as a patient who had been in ED for 38 hours receiving the wrong dose of medication, and a kidney injury partly due to inadequate documentation.
The death of a patient after issues with blood coagulation therapy resulted in a review of emergency department staffing levels, and the department is to review its management of obese patients after a person suffered cardiac arrest.
"All serious events that cause harm to people in our care, and some near misses, are investigated to learn, understand and find new ways of working that will avoid recurrence," Dr Millar said.
"Errors are part of the human nature which we cannot change so our systems must make errors much less likely and provide back up and protection so that a slip or lapse is picked up and harm prevented."
A notable feature in this year’s report was a near doubling of pressure injuries, from six to 11.
In 2017-18, after a surge of such injuries, the SDHB hired a specialist nurse on a two-year contract to improve its management of bedridden patients.
However, in the past financial year incidents included patients left ailing as there were not enough staff to move them, a patient whose injury was not documented as per policy, and a patient who did not have an injury-preventing mattress given to them.
SDHB Chief Nursing and Midwifery officer Jane Wilson said the board believed the increased awareness of pressure injuries had driven the jump in reported cases.
"We have focused on raising staff awareness of the importance of reporting all pressure injuries to provide an accurate picture of patient harm and drive our service improvement activities," she said.
A new SDHB-specific pressure injury prevention training module was now live, Ms Wilson said.
"While there has been progress this year with the initiatives under way, we’ll be continuing this work in the next year and beyond.
"We will not relent on this and other improvement programmes until we have reached our goal of zero harm."
Nationally 975 serious adverse events were reported to the commission, up from 916 the previous financial year.
