76 Deaths, surgical mistakes in New Zealand Hospitals

As one of the old blues songs goes, ‘I laugh just to keep from crying’.  This morning the headlines are out there nationally and internationally. MSN tells the story that in the YEAR ended July 2008, 76 people died out of a total of 258 incidents, that is those that we now about, in New Zealand hospitals.

The story says that the Ministry of Health’s Quality Improvement Committee went on to say that each of these deaths and incidents were avoidable.

The NZ Herald had the story on the front page of the printed edition, but semi buried on the net. They quoted the Health and Disability Commissioner Ron Paterson as saying that it was not a surprise and the story continued to say that ‘Reporting is voluntary and District Health Boards do not know how many incidents are unreported.

Incidents included people’s teeth being accidentally removed, 2 patients being given 10 times the needed dose of medicines, in at least one case, morphine, another patient was booked in, anaesthetised and sent to the operating theatre for an eye surgery they had already had 2 weeks prior. Mistaken identity is another common thread.

Does this come as a surprise to you? It doesn’t to me.

I wrote about these sorts of issues in this blog in February last year. I also presented one of the solutions that has been used in hospitals in the US for many years, at least 15 years ago when Welch Allyn (a well respected technology provider to the health industry) first brought out 2D bar code scanners with the ability to read complex bar codes on patient wrist bands and patient record folders, containing a huge amount of patient information, without requiring access to the hospital’s computer systems. All they would have needed was a number of scanners and a handheld computer such as a Windows CE device (which could also contain a database of things like drug interaction data, i.e. don’t use this drug in combination with that one.

Back in the late 80’s we were already able to come up with a solution that would keep track of patient records folders (which always seem to go missing when you visit the hospital) and are able to identify not only exactly what they are in hospital for, but also things like allergies (especially to drugs such as penicyllin) and any other relevant information such as blood type, currently prescribed drugs (both by their GP and in the hospital and much more.

I presented these concepts and more to Auckland Hospital and the Waitemata DHB. The solution was simple and low cost, but they chose the lower cost option of doing nothing.

So they saved some money and chose to ignore solutions which 20 years ago were strting to be installed in some hospitals in the US. How many lives could have been saved in those years?  I shudder to think. Of course there are also many living victims, who have had to have surgery repeated to remove items accidentally left in their bodies, or many of the other incidents. What about the family of those who died?

So I have a couple of questions:

  • When everyone in the industry new these things have always happened in the industry, why was nothing done about it?
  • Why is it voluntary to report incidents? Why isn’t it mandatory?
  • How many more incidents actually occured that weren’t reported?
  • What are they going to do about it?

You can read the damning report for yourself by downloading this pdf.

If you don’t want to, check out a few of these incidents from the report:

  • Several mental health patients who committed suicide when they should have been under close supervision, or who were discharged and then killed themselves.
  • A patient who died because of confusion over resuscitation status
  • A patient who’s tests suggested cancer which was overlooked
  • Accidental removal of a breathing tube from a ventilated patient
  • Accidental bowel perforation during gallbladder surgery resulting in fatal multi organ failure
  • Death of a mother from post partum hemorrhage due to a number of  ‘errors’

The list goes on for 84 pages and these are only those which were voluntarily reported!

So is the hospital the best place to be when you are sick? You decide.

Are there solutions? Yes there are and there have been for many years. I introduced some of them over 15 years ago and my ideas weren’t new, they were already being introduced into US hospitals at the time.

Are they going to do something about it? I hope so. My concepts don’t solve all the problems, but they could have saved several of these poor people and their families. Who is going to take responsiblity for this? I put it to you that the cost of the solutions is far less than the consequences of not using them at least 76 times over.

If you ask me, the government needs to step in now and do something about it. In many cases there are very simple technologies that will if implemented save many lives, but will also introduce sgnificant cost savings through eliminating some of the inefficiencies that waste time and money.

While this blog is starting to get a good following, I would love to get more readers and encouraging me to keep writing. If you feel that my blog is interesting I would be very grateful if you would vote for me in the category of best blog at the NetGuide Web Awards. Note that the form starts each site with www whereas my blog doesn’t and is of course https://luigicappel.wordpress.com.

Thanks so much for your support:)


6 thoughts on “76 Deaths, surgical mistakes in New Zealand Hospitals

  1. Pingback: Why don’t Auckland Hospitals Work Smarter Instead of Harder « Luigicappel’s Weblog

  2. I’m surprised that you are sharing your story publicly given your experience, but people do need to know what goes on. Kiwis aren’t good at sticking up for their rights, ‘says he who is considering giving up fighting ACC for payment for surgery on a torn elbow tendon.’

  3. I’m sorry to hear about you own hospital mishaps, and I truley do know how you would of felt about your fathers hospital treatment

    Until the other day only a small number of people would of known about my daughters story and what we’ve witnessed, strangely while trying to put this on blog sites my internet connection seems to be getting blocked

    I’ve had an experience recently that has not made me feel very secure, by getting this story online in the public domain leaves the door open for questions to be asked if something were to happen to myself or my family

    In 1993 I seem to have accidently stumbled across (witnessed) very sinister activity – this stuff is way beyond me, truly way out of my league, its is way too big for me to solve, expose or fix and there seems to be some individuals out there who wield power and do not wish this story (or perhaps others like it) to be ever be known, and they’ve proven to me with their ‘berau nurse’ that they’re very serious players

    I know people may laugh, but i don’t think it was just luck that we arrive just in time to save my daughters life, its the only hospital appointment i can remember that miraculously finished early, right down to getting the right carpark which allowed us to there, save our daughter from death, we were literally seconds away from disaster, I believe God helped saved her life, every single time we’ve come up against their obstacles or discrimination from Govt Depts, we’ve managed to find just the right person or tactic to see us through, since that very day in 1993, I’ve experienced extreme discrimination from Govt Depts, concerning my daughter I honestly believe its linked to what I witnessed that day 16 years ago, its been far too extreme to be swept under the carpet as mere cocindence

    When dealing with Govt Depts we have found that we’re only successful if we use a ‘third’ party a witness, knowing your rights is really not enough, and I’ve also found that Govt Employees are beyond the law, I’ll give an example:
    we’ve had to use the Patient Advocacy Service to stop discrination of my daughter and access entitlements (a simple disability allowance to cover medical cost) other NZers take for granted,
    the Govt Dept employees in question were found to have broken almost EVERY single law under the Code of Health and Disabilities Act – No prosecutions followed, hmm could you imagine say the Police raiding a gang pad, finding all sorts of goodies, but instead of arresting them, saying you people have broken the law, but if you promise to be good little boys and girls – we’ll let you off

    from once being a Govt Employee myself (ex-soldier) I use to think system was ok, had some faults, but you know, ok, my eyes have been really opened since 1993, I never thought these sort of things could ever happen here in New Zealand, I now trust no one who is a Govt Employee be it the Police or Healthcare Services

    If this has happened to my daughter, this may of well of happened to others too, and if your reading this and your having problems with the health system or other Govt Depts, always use a third party – a witness, and no matter how hard or unfair it seems, please DON’T GIVE IN

  4. That’s an incredibe story! I can easily believe it though. I haven’t had anything like that, although I have had major allergic reactions to 2 drugs I was given at the same time that the Ethicals (The quarterly medical drug book for doctors and hospitals) says should never be prescribed together.

    My father in law has a layngectomy and almost every time he has been to hospital for anything he has ended up with pneumonia and often extra complications.

    The main problem I’ve had with my family is going to A&E and waiting for 6 or more hours to be seen and up to 48 hours in corridors before being admitted into a ward. North Shore had a standard excuse that a registrar was of sick and they were therefore down a team. Now the reports have shown that they are one of the worst performing hospitals in NZ, despite being in one of the fastest growing areas.

    So lucky you were there in time. I have just been in Southern Cross Hospital for a minor surgery and one night stay. I feel really lucky that I can afford (just) Southern Cross Medical Insurance. If I had had to go to a public hospital for it, I would have put it off indefinitely.

    Southern Cross staff were wonderful accross the board. I know the problem in public hospitals is largely due to management and most of the staff are fantastic, but you can’t expect quality treatment when you rely on bureau staff to make up the numbers and expect junior doctors to regularly work double shifts. Isn’t it funny that we let a junior doctor work for 16 hours, but we would never let a truck driver work anywhere near that. Is there something wrong with this?

  5. I’ll keep this brief as possible:
    In 1993 – 16 years ago when my daughter was in Hospital (she was about two years old at the time)- waiting to be flown to Starship hospital Auckland for surgery following “mistakes- accidents” caused by Doctors in ChristChurch

    At that stage while we were in hospital, we the parents were doing ALL here cares for her gastronomy tube – (trust was gone)

    we had an appointment at ChCh Womens hospital (partner was pregnant), we mistakenly thought it’ld be safe to leave Angel in the hospital ward – while we went to the appointment
    – lucky for my child the appointment finished early

    when we came back to ChCh public Hospital (a few days before my two year old child had been put in a room by herself, -not the the big ward rooms with other patients or witness)
    as we entered her room there was a ‘bureau nurse’ a nurse i’ld never seen before(not one of the regular nurses from the ward, or hospital nursing staff)
    she had a kettle of hot boiled water in one hand in her other hand was Angels open gastronomy tube(plastic tube that leads straight into the stomach) just about to pour it down

    I immediately asked her ‘what the fuck are you doing?’
    she replied she was just going to clean her gastronomy tube, i said are you a idiot thats boiling hot water
    she left the room, walked down the corridor – and never returned – she did not stay on the ward to complete a shift

    my first thoughts were how could she be so stupid – after she left – never to return it occurred to me what had actually happened, what we had just witnessed
    the boiling water would of in all likelihood of have killed her, the implications were huge, we the parents would have got the blame, (framed, imprisoned for a crime we never committed) as we were doing ALL her gastronomy cares, and to rub salt in the wound my unborn son would have been taken from us as well –
    since that very day, we have come up against brick walls and EXTREME discrimination from Government Depts
    eg: 9 months to get a disability allowance processed, review after review after review(this is ALL on Govt record – they keep documents, I have copies as well) we seem to be the only New Zealander’s in this entire country of 4 million people who cannot receive entitlements that by law – ALL other citizens take for granted

    i’ve had to live with discrimination and the fear of myself and families well being for the last 16 years, dead people don’t talk, the discrimination still happens, today which indicates they’re not prepared to forget or leave us alone either, i believe having told others and keeping files of my child Hospital records of their mistakes with others is the reason i and my family are still here
    my only crime i can see for deserving this Govt discrimination was walking in and preventing my child from being killed – and yes i’ld do again in bat of an eyelid
    People Need To Know

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