A patient on a ventilation machine at home who died because
of a power failure is one of 40 medical mishaps recorded by
the Southern District Health Board in 2010-11.

Yesterday, the Government’s Health Quality and Safety
Commission released its serious and sentinel events report
for 2010-11.

Listed are 377 serious or sentinel events, with 86 deaths,
although the deaths were not necessarily a result of the
events. A sentinel event is deadly or life-threatening; a
serious event requires significant additional treatment.

SDHB (Otago) chief medical officer Richard Bunton indicated
he would respond today to Otago Daily Times queries, as he
did not have time yesterday.

In 2009-10, when Otago and Southland’s events were counted
separately, the two former boards had 48 events.

In a departure from previous years, outpatient suicides are
not included, with another reporting method being developed.
Inpatient suicides are still counted, of which two were
recorded by the SDHB.

Overall, the SDHB had the fourth-highest tally of the
country’s 20 DHBs, behind Auckland (56), Waikato (53) and
Canterbury (49). It is the sixth-biggest DHB by population.

Of the 40 SDHB events, 14 were sentinel.

After the ventilation machine death, three machines were
bought to provide back-up battery power for homes.

A delay in resuscitating a patient in an unspecified ward
might have contributed to another death. A review found
members of the resuscitation team were unaware of their
roles, which led to no-one taking charge. The review
recommended staff working a high number of night shifts be
required to undertake CPR certification at level 5 or 6.

In another case, a misdiagnosis led to a neurological
complication, osmotic myelinolysis, requiring intensive
treatment and rehabilitation. A review found low-sodium meals
had not been provided as requested, resulting in improvements
to meal systems.

Another death occurred after a mental-health patient took
illegally obtained methadone.

Mental-health staff would be educated about the risks of
recreational methadone use.

A death in a “remote site” occurred because of delayed
emergency treatment. An investigation was under way and
further details were unavailable.

Another patient died from a burst aorta after back pain was
misdiagnosed in an emergency department. After the patient
was discharged, there was a delay reviewing the X-ray, which
could have picked up the problem.

A process for quicker X-ray reviews for ED patients was
recommended.

A 10-month radiology delay meant bladder cancer developed
further than it should, which was flagged as a “serious”
event. The referral had been wrongly marked non-urgent.

An investigation of another “serious” delay diagnosing cancer
found issues with how abnormal scan results were handled.

A patient was paralysed because of another radiology issue
when a spinal lesion was not picked up on a CT scan. It was
later found on an MRI.

A child’s death might have been prevented had they been
admitted earlier to the intensive care unit, another case
said. The child had complex underlying health conditions.

An organisational risk alert was issued after a nasogastric
tube was misplaced, resulting in a death. An investigation is
under way.

An intravenous cross-contamination of a medicine (Fentanyl)
between two patients happened when a syringe was not
discarded. The outcome for the patient was not noted in the
“serious” event, but it led to staff education on correct IV
protocols.

In another medication error, a patient was given five times
their usual opioid dose. The mishap arose from confusion
between millilitres and milligrams, and led to the patient
being treated in the high dependency unit.

Another error in medication caused the termination of a
“potentially viable” pregnancy. A review found: “Treatment
commenced based on [the patient] presenting symptoms and
diagnostic information … leading to a misdiagnosis of an
ectopic pregnancy.”

Falls, the single biggest category in the national tally (195
events), accounted for 10 of the SDHB’s events, a quarter of
its total.

An increase in the overall tally of serious and sentinel
events from 2009-10, when there were 318, was attributed to
the rise in falls.

Eleven patients either had surgery performed on the wrong
body part; received the wrong procedure; or missed treatment
altogether when it was performed on the wrong patient.