Wairarapa Hospital. PHOTO/FILE
Learnings from baby death, forgotten swab, and a fall
A baby died while being delivered, a swab was left behind in a patient’s body after an operation, and a confused hospital patient, at risk of falling, fell and broke their leg.
These “adverse events” which happened from July 1, 2018, to June 30 this year were reported to the Health Quality and Safety Commission by the Wairarapa District Health Board.
The baby who died during delivery was in a breech position [legs/bottom first], but this was not picked up until the late stages of labour.
Instead, it was believed the baby was a head-first presentation and the delivery was managed as such.
The baby died as a result.
A review of the failed delivery found best practice guidelines, and DHB policy and procedures were followed.
The DHB made some “incidental findings” although they wouldn’t have affected the outcome, it said.
Since then, the DHB said it had improved support processes for bereaved parents and whanau, and follow-on care in the community post-discharge.
In the case of the broken femur [leg bone], a hospital patient was placed in a close observation bed space because they had mild confusion and were at high risk of falling.
When the patient unexpectedly tried to move, they fell.
The DHB said that a patient “watch” may have prevented the fall, however an assessment before the fall didn’t indicate they needed a full watch.
Another patient had a swab left in them during surgery, and a second surgery had to be done to remove it.
The DHB found that there was poor communication between team members, and a count of the materials used during surgery wasn’t done until after the surgery.
Staff were re-educated on the surgical count policy and the DHB’s safe surgery policy was updated, and policy familiarisation was made a standard part of staff orientation as was a reorientation of returning staff.
Wairarapa DHB chief medical officer Shawn Sturland said staff worked hard to prevent adverse events, “but when things do go wrong and people are harmed, we act swiftly to learn from those events and then share that learning to prevent it happening again”.
“We call these failures adverse events.
“But what we are really talking about is patient harm. There are people in the centre of these stories and, usually because of failures in systems or processes of some sort, they have been compromised.
“For that, we apologise, and from that, we learn.”
This year, Wairarapa DHB reported three adverse events.
Last year, seven events were reported and eight in 2017.
Capital and Coast DHB reported 36 adverse events this year, and Hutt Valley reported 13.
The highest number of adverse events reported was at Canterbury DHB with 77, followed by Waikato and Waitemata with 62 apiece.
Suicide data is not included in the adverse events report.