Adverse Events
Reporting adverse events nationally signifies an important step on the road to improving health outcomes for New Zealanders.
 

The key is to improve safety by encouraging open and transparent reporting of incidents when something goes wrong.

The intention of the report is to support DHBs' continuous quality improvement focusing on shared learning to move towards improving systems and minimising the possibility of future incidents.  


Visit the Health Quality and Safety Commission website for more information.

 

 

Event summary 1

 

 

What happened?

A patient underwent a planned hysterectomy. A blood test for haemoglobin taken the day after surgery identified the patient had suffered a bleed which was not detected earlier.

 

What did we find?

Our review found that the patient had appeared to be recovering as expected on her first day after the operation. Her heart rate was slightly elevated and her blood pressure was low overnight. These observations were thought to be related to pain and the effect of pain medicines. The patient’s observations taken did not trigger a flag to indicate a review by a doctor was needed.      

 

What did we do?

The patient received three units of red blood cells and two units of fresh frozen plasma. The patient was taken back to theatre for an exploratory operation. This identified four sites of bleeding and these were treated. The fact the patient vomited after her operation and was given medication to prevent blood clots was thought to have contributed to the bleeding. The patient made a full recovery.

 

 

Event summary 2


 

What happened?

A patient from an inpatient mental health rehabilitation ward was out on a staff-accompanied group walk when he tripped on the footpath and fell fracturing his nose. Treatment was administered in the Emergency Department and the patient recovered quickly without complication.

 

What did we find?

A review team found the reason the patient tripped was the poorly fitting open-toed sandals he was wearing. The patient was at risk of harm as he was over the age of 65. Falls prevention, education and support were not targeted at the inpatient mental health wards therefore falls risk screening had not been established as standard practice.

 

What did we do?

It was considered that reducing the risk of falls in the rehabilitation environment must be strengths- based, promote normalisation, and not restrictive to the enjoyment of daily life. The patient was supported to purchase properly fitted safe walking shoes to be worn on all walks outside the ward. Falls reduction education was presented to the staff and patients by the HQSC national lead for reducing harm from falls. Falls risk screening was introduced to the ward. The patient had a physical evaluation focusing on age-related screening and was evaluated for bone health. A business case was submitted which enabled all the patients to procure good-quality, well-fitted shoes to promote safety when out walking.

 

 

Event summary 3


 

What happened?

A female inpatient in the Medical Ward slipped while moving independently. She fell onto her wrist and sustained a fracture.

 

What did we find?

Following an in-depth review it was found that the patient was a falls risk and had been referred and assessed by the multi-disciplinary team.  However, administration of pain relieving medication which increased the likelihood of being unstable and not wearing slippers over the socks the patient wished to wear were contributing factors which lead to the fall.

 

What did we do?

Delivering the right information and education regarding medication and footwear risks has been a focus with our staff.  Changing the way in which the education of these risks is then provided to our patients is part of our falls care plan improvements.

 

 

Event summary 4


 

What happened?

A patient had an ultrasound of his renal tract. The examination identified a ‘mass right bladder’, which wasn’t changed to ‘exam done’ in the electronic system, so therefore was not available for the radiologist to report on.  

 

The unreported ultrasound was discovered three months later, when the new radiology electronic system was implemented. The patient was not aware of his examination results, as he had been previously informed by the general practice team that he didn’t need to contact them for the results - the practice would contact him if there were any concerns with any results. Because he was not contacted he believed for three months that ultrasound results were normal. 

 

The general practitioner was on leave and the locum was not aware that examination results were not available.

 

What did we find?

An investigation found the unreported ultrasound was discovered only by chance during migration to the new electronic radiology system. The sonography process required updating and there were inconsistencies within the process by the sonographers.

 

There was no auditing schedule in place. Providing information for patients about when and how to receive their examination results was not standard practice.

 

What did we do?

The patient was informed and referred urgently to the urologist, and surgery was completed. The delay in the examination result was not believed to impact on the patient’s prognosis. 

 

The DHB is ensuring policies and procedures reflect sonographers’ responsibilities and accountabilities. Clinical processes of auditing and checking have been put in place that will act as a safety net to ensure all ultrasounds are reported on.  The Radiology Department has learnt from this event and it is committed to make the changes needed.

 

Notices are being developed for the radiology waiting rooms to inform patients/family/whānau that their general practitioner or specialist should receive their results within five working days. 

 

 

Event summary 5


 

What happened?

A patient lodged a complaint about the time it had taken after his prostate cancer was diagnosed, to commence treatment. He felt this led to a poor outcome.

 

What did we find?

Following an investigation it was found that in this case the delay was due to the patient’s circumstances and the outcome for the patient would not have changed.

 

What did we do?

There were no systems or process issues identified by the investigation. There was no requirement to do any further analysis of this case.

 

 

Event summary 6


 

What happened?

The patient’s family lodged a complaint of delayed diagnosis with the Office of the Health and Disability Commissioner. The patient had been investigated for abdominal pain since 2013. A review of the CT images from September 2016 showed inoperable cancer of the pancreas. Sadly the patient passed away three months later.

 

What did we find?

The patient was extensively investigated with endoscopic procedures, ultrasound, CT and MRI scans and no cause of her persisting symptoms was found. Her gallbladder showed signs of chronic gall bladder disease however her symptoms did not abate after this surgery.

 

The surgeon viewed the radiologist’s report of the CT scan which stated ‘no significant abnormality detected in the abdomen or pelvis’, but the surgeon did not have access to the actual images from his private rooms.  The CT images from September 2016 were viewed by three other radiologists who all detected the pancreatic cancer. The error was reported incorrectly by the radiologist. Whanganui District Health Board lodged an Accident Compensation Corporation (ACC) Treatment Injury claim which was declined by ACC.

 

What did we do?

The radiologist who incorrectly reported the CT images acknowledges the error and has learnt from this event. Expert opinion confirms that pancreatic cancer is not identified in many cases until the disease is in a late stage. The surgeon now ensures he views all CT images and does not rely on the report alone. Whanganui District Health Board is committed to implementing any recommendations which come from the Health and Disability Commissioner when his investigation is completed. We offer our sincere condolences to the family.

 

 

Event summary 7


 

What happened?

The patient presented to Whanganui Hospital’s Emergency Department and was given a diagnosis of bowel disease following a CT scan. A referral was made to the Surgical Department and the patient consented to an operation to remove a portion of her bowel which was extensively diseased. At the time of the operation, a bowel cancer was seen and completely removed. The surgeon requested that a radiologist review the CT scan images the next day to see if the cancer was showing. The radiologist confirmed that the cancer was not showing. The patient made a full recovery and has been discharged from surgical outpatient follow up.

 

What did we find?

There were no system or process issues present in this case and the cancer was not evident on CT scanning.

 

What did we do?

We requested that two other radiologists review the CT images to rule out human error. These radiologists confirmed the conclusion made by the first radiologist.

 

 

Event summary 8


 

What did we find?

The patient was admitted to the Acute Inpatient Mental Health Unit for several weeks. During this admission she was observed to be unsteady on her feet and very frail due to poor nutritional intake. She was not keen to move around and spent long periods of time in her bed which led to pressure areas developing. The patient had five falls during her admission, the fifth resulting in a fractured femur. She was transferred to the Surgical Ward for repair of the fracture.

 

What did we find?

The Acute Mental Health Inpatient Unit was not equipped to care for the frail elderly. The patient’s mental state risks and plan of care were well documented There was no consistent documentation of the risk of falls and pressure injuries that the patient suffered and no documented plan for the physical care the patient required.

 

What did we do?

We are rolling out to mental health, the combined risk assessments and care plans which include pressure injury and falls prevention strategies as used in the rest of the hospital. We are developing a shared care model, between mental health and medical staff for patients with physical and mental illnesses.

 

 

Event summary 9


 

What happened?

A child attended a general practice on 26 June 2017 with gastroenteritis symptoms. He was seen by a doctor and referred to Whanganui Emergency Department where he was reviewed by a senior paediatrician.

 

After review he was admitted to the Paediatric Ward where his condition continued to deteriorate. The decision was made to transfer this patient to a tertiary hospital, which occurred in a timely manner. Upon arrival at the tertiary hospital his condition continued to deteriorate and he sadly passed away on 27 June 2017.

 

What did we find?

The medical condition that this young child had is rare and has a high mortality rate. He was cared for by experienced senior medical personnel and every possible intervention was performed in order to treat his critical condition.

 

What did we do?

We offered our sincere condolences to the family and advised them of our investigation process.