Adverse Events

Reporting adverse events signifies an important step towards improving health outcomes for New Zealanders.

wanganui hospital emergency department1 lrgAn adverse event is an event with negative reactions or results that are unintended, unexpected or unplanned.

 

In practice, this is most often understood as an event which results in harm to a client.

 

Under the National Adverse Events Reporting Policy 2017, Whanganui DHB is expected to:

  1. report serious adverse events;
  2. undertake formal review of serious adverse events.

Clients and their whānau who have been involved in an event will be offered the opportunity to share their story as part of the review process. In turn, review findings and recommendations will be shared back to them. 


The intention of this page is to provide an annual summary of adverse events to support WDHB's ongoing quality improvement, focusing on shared learning, improving systems and minimising possibility of future incidents.

 

We aim to improve safety by encouraging open and transparent reporting when something goes wrong.

 

Related documents

 

Adverse events - Media release 21 November 2019

Adverse events - FAQs 2019

Adverse events - Annual report 2019/19

 


Visit the Health Quality and Safety Commission website for more information.


The following are the most recent events investigated and their outcomes:

 

Event summary 1


This is an historic case involving care provided between 2011 and 2013. A surgeon and the Whanganui District Health Board were found in breach of the Health and Disability Commissioner Code of Health and Disability Services Consumers’ Rights Regulations 1996. For full details go to the HDC website www.hdc.org.nz and enter the reference 14HDC00828. 

 

Event summary - 2


What happened?

 

The patient underwent chemotherapy and radiotherapy for cancer and was to be followed up in outpatient clinics at six-weekly intervals. The patient was lost to follow up for seven months and when seen had a recurrence of the cancer.

 

What did we find?

 

A new patient management system had been implemented and staff were not familiar with the processing screens. The clinic outcomes for “discharge” and “follow-up” were next to each other increasing the potential for operator errors of this kind.

 

What did we do?

 

We acknowledged and apologised for the delay and lodged an ACC treatment Injury claim on the patient’s behalf. We fast tracked referrals to specialist services at a tertiary hospital so that the patient could receive the right expertise and treatment in a timely manner.

 

Event summary - 3


What happened?

 

The patient was moving from the bed to reach a walking frame in order to mobilise to the bathroom when she tripped and fell. The patient had small lacerations and sustained a fractured pelvis.

 

What did we find?

 

The patient had been assessed by therapy staff and deemed safe to mobilise with the assistance of a walker. The patient had a current falls risk assessment documented. The patient felt that she tripped as her slippers were loose fitting.

 

What did we do?

 

We ensured that there were sufficient supplies of non-slip socks on the ward and educated staff on how to conduct footwear assessments in the context of falls prevention.

 

Event summary - 4


What happened?

 

The patient had a pressure injury present on admission however this deteriorated to a stage three pressure injury despite utilising pressure injury prevention measures.

 

What did we find?

 

The patient was assessed as high risk and placed on an air mattress with a regular turning schedule. The patient’s care plan was updated daily and regular skin inspections were undertaken. Not all new graduate staff had completed pressure injury prevention training.

 

What did we do?

 

We lodged an ACC treatment injury claim on the patient’s behalf. We implemented visual cues at the bedside for pressure injury risk patients and ensured that all new staff completed pressure injury prevention training.

 

Event summary - 5


What happened?

 

The patient was admitted to the Medical Ward for treatment of a cardiac condition. The patient fell onto his walker in the bathroom sustaining skin tears, grazes, a fractured clavicle and finger. Unfortunately the patient’s health continued to decline over the next fortnight and the patient died.

 

What did we find?

 

The patient had a history a feeling faint or fainting after using spray to relieve his chest pain. This was known to the doctor but not passed on to the nurses caring for the patient. Shortly before the fall the patient had used the spray and it is thought that this contributed to the fall.

 

What did we do?

 

We assisted the family with lodging an ACC claim and reviewed the orientation for new staff to ensure it covered medical risk factors associated with falls. We audited patient care plans to make sure they reflected the patients’ history and medical risk factors for falling.

 

Event summary - 6


What happened?

 

A patient known to the Whanganui District Health Board (WDHB) mental health and addiction services was an inpatient under the care of staff in the acute inpatient psychiatric unit. The patient was administered medications to treat their mental health condition. The medications caused a heavy level of sedation noted by long periods of sleep compressing the patient’s left forearm and highly likely led to the development of compartment syndrome (pressure building up inside a muscle compartment causing injury to muscles, nerves and blood vessels).

 

What did we find?

 

An in-depth internal review determined that the best evidence guidelines for monitoring patients following the administration of medications for rapid tranquilisation were not followed. There was  a lost opportunity to ensure that the level of consciousness was monitored, the patient nursed in a safe position and place, vital observations taken and position changed regularly which would have prevented a heavily sedated patient sleeping on their arm and developing compartment syndrome.

 

What did we do?

 

We reviewed the management and guidelines for monitoring a patient following rapid tranquilisation. Nursing staff received education and training on the assessment of the risk and care required to prevent pressure injuries developing and a form was redesigned to better capture the care provided. The review findings and recommendations have been shared with staff in the adult inpatient psychiatric acute unit. WDHB takes full responsibility for the development of the compartment syndrome. The review team acknowledges that this sad event could have been prevented.

                                                     

Event summary - 7


What happened?

 

The patient was admitted for cataract surgery and developed increased pressure in her eye shortly after the surgery began. The ophthalmologist ordered a medication to be given however the staff could not locate the medication in the strength that was required. There was a delay in obtaining the medication from another area of the hospital and a further delay in waiting for the medication to work. The patient then developed a leak of eye fluid which required a specialised machine to treat. The staff initially could not get the machine to operate which cause a further delay. Aware that the delays increased the chance of the patient developing an infection in the eye, the ophthalmologist prescribed antibiotics and discussed the risk with the patient. Unfortunately the patient developed and eye infection on the second post-operative day which did not respond to treatment and led to the patient having the eye removed.

 

What did we find?

 

No surgical briefing took place prior to the start of the operating list that day. The medication requested by the ophthalmologist was available in the operating theatre but at a lesser strength and under a brand name which staff did not recognise. The staff were not aware of all the settings on the specialised machine. The reasons for the delay could have been better communicated to the patient for the duration of the delay.

 

What did we do?

 

We lodged an ACC treatment injury claim on behalf of the patient and referred to a tertiary hospital for further treatment. We commenced a surgical briefing for all ophthalmology operating lists. We ensured the correct strength of the medication was stocked in the operating theatre and was correctly labelled. All staff undertook education and training on the use of the specialised machine including problem solving and trouble shooting. This case was presented at peer review with a focus on communication to patients having a local anaesthetic. We instituted an audit of ophthalmology consent forms to monitor their completeness.

 

Event summary - 8


What did happened?

 

The patient developed acute pancreatitis following an endoscopic procedure and despite intensive treatment died three days later.

 

What did we find?

 

This was a serious complication with a high mortality rate. We referred this case to an independent expert upper gastro-intestinal surgeon for an independent opinion. Due to unforeseen delays the review is yet to be completed.

 

What did we do?

 

We have met with the patient’s family and offered our condolences. An ACC treatment injury claim was lodged and has been approved. Further actions may arise once the review is completed.

 

Event summary - 9


What happened?

 

A premature infant was born in Whanganui Hospital and transferred to a tertiary neonatal intensive care unit for ongoing care and treatment. Premature babies need to be screened for damage to their retinas which can lead to loss of vision. There was a delay in examining the infant’s eyes on return to Whanganui Hospital. A doctor made a referral to the ophthalmologist however this was not accepted as it did not contain enough information.  A further referral was sent to the ophthalmologist. When the eye examination took place there was significant retinal damage and the infant was assessed by specialists in two tertiary hospitals. Sadly the damage could not be repaired and the infant is blind in one eye and almost completely blind in the other.

 

What did we find?

 

The tertiary hospital where the infant was cared for did not handover the need for screening in his discharge summary and did not indicate that retinopathy of prematurity was present at the infant’s 32 week check. Staff did not act on questions from the infant’s parents about retinal screening when asked. The existing admission and discharge assessment and checklists were not explicit enough regarding retinal screening. The first referral to the ophthalmologist did not indicate urgency and was not accompanied by a phone call. The request for more information regarding the first referral was sent to the infant’s GP rather than the hospital doctor who made the referral. This added to the delay.

 

What did we do?

 

We apologised to the family and assisted with lodging an ACC treatment injury claim. We formed an investigation team, consulted with neonatal specialists and reviewed best practice guidelines for retinal screening in premature infants. We have added the responsibility for retinal screening to the role of the clinical nurse manager, paediatrics. The nursing assessment document has been updated to include retinal screening. We will be implementing Kōrero mai in the paediatric ward. This is a programme which involved family members and friends raising concerns and staff listening to and acting on these. The paediatric department will phone through (as well as sending a written referral) all urgent referrals to the ophthalmology department.

 

Event summary - 10


What happened?

 

The patient presented to the Emergency Department (ED) five times over a six month period and was treated for infections. The patient was seen by an ear nose and throat surgeon and an outpatient scan was ordered. Three days after this appointment the patient presented to ED in a critical condition and a brain abscess was diagnosed. Sadly, despite intensive treatment in a tertiary hospital, the patient died.

 

What did we find?

 

The investigation is underway.

 

What did we do?

 

We have expressed our sincere condolences to the patient’s family and they are involved in our investigation process.

 

Event summary - 11


What happened?

 

The patient was admitted for pain management and assessment. Physiotherapy and occupational therapy staff assessed the patient’s mobility as being independent with a walking frame and needing one person supervision when transferring from bed to chair. The patient requested to use the bedside commode during the night and was supervised to transfer onto the commode however the patient leaned forward and slipped to the floor. The patient sustained a fractured shoulder which was treated conservatively.

 

What did we find?

 

The patient was compliant with ringing the call bell and the supervised transfer but lost their balance and was supported to the floor by the registered nurse. The patient was recognised to be a falls risk and the clinical documentation reflected this risk.

 

What did we do?

 

We lodged an ACC claim on the patient’s behalf and arranged for additional personal cares when discharged home. We review the equipment used on the wards to assist with patient transfers and purchased two standing aids for patient use. Falls education regarding complex patients was completed for the ward staff.

 

Event summary - 12


What happened?

 

The patient had an elective procedure to place a feeding tube into his stomach while being treated for an oral cancer. The next day the patient became unwell and an operation revealed a small bowel perforation which was repaired. Unfortunately the patient continued to deteriorate and died two days later.

 

What did we find?

 

We found that the feeding tube was correctly placed using a best practice technique. There is a recognised mortality rate for this procedure.

 

What did we do?

 

We have offered the family our condolences and shared our findings with them.

 

Event summary - 13


What happened?

 

The patient was admitted to a ward from a rest home. The referral from the rest home stated that the patient’s skin was intact. Six days later the patient was transferred to another ward and at the handover it was stated that the patient’s skin was intact. The following day a pressure injury was noted on the patient’s heel. This injury was described as a suspected deep tissue injury.

 

What did we find?

 

The patient was identified as being at high risk of developing a pressure injury and this was documented on the care plan and identified on the patient’s bedside whiteboard. No skin inspection took place when the patient transferred to another ward.

 

What did we do?

 

We nursed the patient on a pressure relieving mattress and instituted a turning schedule. We lodged an ACC treatment injury claim on the patient’s behalf and made a referral to a wound nurse specialist. The injury was downgraded to a stage three pressure injury once it was assessed and treated by the wound nurse specialist. We provided further education to staff on the importance of skin integrity checks each time a patient has been admitted and transferred and also prior to discharge. We provided a resource to ensure staff are able to correctly stage pressure injuries.