Wairarapa DHB reports nine serious incidents, including a death
ELI HILL
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One patient caught fire during surgery, and another died after a colonoscopy at Wairarapa Hospital between July 1 last year and June 30 this year, according to adverse events reported to the Health Quality and Safety Commission.
They were two of nine adverse events reported by the Wairarapa District Health Board.
Three of the adverse events were colonoscopy related.
An elderly patient with a variety of chronic health problems died after undergoing a colonoscopy.
The DHB reviewed its procedure and found that patients with previous health problems should have a clinical appointment beforehand to look at the risks involved in the surgery.
One patient needed to be transferred to another hospital after suffering a bowel perforation during a colonoscopy and biopsy.
Another patient also needed to be transferred to another hospital after undergoing a colonoscopy and receiving a bowel perforation. The patient had other health conditions and was on anti-coagulant medicine.
To ensure both events wouldn’t happen again the DHB purchased a new endoscopy machine and ensured they had clear procedures going forward.
Wairarapa District Health Board communication manager Anna Cardno said the number of endoscopies had significantly increased since the initiation of a bowel screening programme for men and women last year.
“Being such a commonly-performed procedure, colonoscopies do reflect in these figures.”
Cardno said that like all surgical procedures, colonoscopies have identified risks.
One of the more unusual reported events was a patient catching fire while undergoing diathermy, a surgical technique involving the production of heat through applying electric currents to the patient’s body.
The patient received burns around their knee and had to undergo surgery and skin grafting as a result.
After a review the hospital found that products containing alcohol should be taken out of the operating theatre when surgery is performed, and skin should be given time to dry after alcohol products are used.
After undergoing a knee joint replacement and getting an infection that didn’t respond to treatments a patient was left with a fused joint.
A review found that the hospital had provided appropriate care, backed up by expert advice that said tracking down the source of the disease would’ve been difficult.
An elderly patient already suffering from a fractured femur [leg bone] fractured their humorous [arm bone] after falling in the bathroom.
While a review is still in progress the DHB will add a falls education session to its update days for staff.
Three mental health events were also reported, but further information on them was not made public.
Cardno said, “We continue to encourage a reporting culture, and support staff to review and improve systems and processes where the opportunity arises.”
The number of adverse events reported in Wairarapa have grown slightly, the nine reported this year up from eight the year before, and three, two years ago.
New Zealand wide there were 982 reported adverse events, 631 reported by district health boards.
Clinical management events were the largest number of events reported by DHBs with 317 reported New Zealand wide.
DHBs reported 255 incidents of harm caused by falls, 31 to do with infection, 20 for medication or IV fluid, five due to consumer accidents and three due to medical devices.
Wairarapa DHB Adverse Events
July 1, 2017-June 30, 2018
- Patient caught fire during surgery
- Elderly patient died after colonoscopy
- Two bowel perforations during colonoscopies
- Fused knee joint as result of infection
- Patient with broken leg fell, breaking arm
- Three mental health events
