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Fourteen patients were seriously harmed at Wairarapa Hospital in the past financial year, more than double the number recorded two years ago.
The figure, cited in the Health Quality and Safety Commission’s [HQSC] yearly review of serious and fatal events at Wairarapa District Health Board [DHB], included two incidents that resulted in either death or permanent severe loss of function.
Both these incidents, which occurred during a clinical procedure, received a category 1 Severity Assessment Code [SAC 1] and were classified as severe.
The further 12 events recorded, were classified as SAC 2, or major adverse events, having caused permanent major or temporary severe loss of function to the patient.
Of the SAC 2 events, eight happened during a clinical procedure, three were recorded as falls, and one was a patient accident.
The effects of adverse events are not related to the patient’s natural course of the illness, differ from the immediate expected outcome of the patient’s care management, and can include sensory, motor, physiological, psychological or intellectual damage to the patient. None of the staff present during these incidents where patients were harmed were asked to leave.
The total number of adverse events in the 2021-2022 financial year at Wairarapa DHB was eight more than in the 2019-2020 financial year. HQSC was unable to provide the numbers 2020-2021 financial year due to a change in reporting methods.
Te Whatu Ora Wairarapa interim district director Dale Oliff said the hospital was always concerned when adverse events occurred and that each would be reviewed by the HQSC.
“Adverse events allow us to make improvements like the ACC pressure injury project we have recently started and the appointment of extra nursing resources to focus on fall prevention.”
When asked whether either of the recent severe events resulted in death, Health NZ Wairarapa withheld the information under Section 9[2] of the Official Information Act, citing the privacy of natural persons, including deceased persons.
Privacy was also used as a reason not to divulge information about the nature of the adverse events or the clinical procedures that were under way when patients were harmed. Te Whatu Ora apologised to the families and patients harmed.
HQSC system safety and capability senior manager Caroline Tilah said the commission looked at the individual adverse event reports from a healthcare quality perspective, but only if requested by the health provider.
“We are currently completing our annual review of all SAC 1 and 2 events from the 2021-22 financial year to inform national learnings and where we can support further thematic analysis.”
