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.
