Prompted by the death of a road-crash patient at Southland Hospital during a CT scan, an investigation recommended a review of trauma protocol, and installing an alarm linking radiology and the emergency department, the just-released report on medical mistakes revealed.
The 2009-10 serious and sentinel events report itemises Southland and Otago's mishaps separately; the two boards merged in May to form the Southern District Health Board.
Southland had nine serious or sentinel events, compared with 11 last year, and 18 in 2007-08.
A sentinel event caused death, was life-threatening, or led to disability, while a serious event required significant additional treatment.
Southland had four sentinel events, three of which were community mental health patient suicides (one suspected, two confirmed), resulting in no recommendation.
An investigation following the CT scan death recommended a review of trauma protocol; that handover of care between specialties be standardised to ensure continuity; job titles be clearly displayed; and consideration be given to installing a cardiac arrest alarm from radiology to the emergency department.
The investigation found trauma protocol had not been correctly followed, a team leader was not assigned, team members could not be clearly identified, and handover between staff lacked co-ordination.
The patient had sustained multiple fractures in the crash, including pelvis and chest trauma.
Southland interim chief medical officer Murray Fosbender confirmed all of the recommendations had been accepted, but he urged caution about blaming what occurred in the hospital for the death of the patient, whose injuries were critical.
However, in his view the patient should have been kept in the emergency department, rather than taken for a scan.
He emphasised the cause of death was yet to be determined by the coroner.
Mr Fosbender said it was pleasing Southland's adverse events had fallen.
While having their mistakes aired made doctors "cringe", it was beneficial for the health system, which became "sick" if mistakes were kept secret, Mr Fosbender said.
