Accidental hospital deaths plummet from estimated 750 to 40 actual

This is either a remarkable improvement or the figures are understated. To say they are understated is itself an understatement: we’re talking about more than a tenfold understatement. National party health spokesman Tony Ryall said “the committee’s figures vastly understated the size of the problem”. He’s not wrong.
The NZ Herald article states,

“Committee member Dr Mary Seddon, the clinical director of the Counties Manukau board’s quality improvement unit, said there were more preventable incidents than had been included in the report.”

I’d expect that “more” to be maybe 10-20% more. What was the real number? Will we ever find out?

A May 2007 report into accidental hospital death (The Press, Christchurch) put the figure at an estimated 750 each year (see our original blog post) but the recent report released stated only 40 deaths in the past financial year.

40 preventable deaths from 834,000 admissions is a fantastically good result - a pity it’s not the real number.

How about we take a look at the report? Where do we start - Ministry of Health or the Health and Disability Commissioner?

Let’s try the HDC first - go to Publications - then Other Reports where we find the Safety of Patients in New Zealand Hospitals: A Progress Report known here as the “plethora of policies” report. OK - that was October 2007 - nothing since then.

Must be on the Ministry of Health website - go to Publications and Resources and Find by Date. Not there! OK - so since we’re there let’s have a look at Quality Improvement since it’s a hot topic. Quality Improvement - Publications - nothing since 2004 (could this have anything to do with “slow and patchy” progress?) However, under Toward Clinical Excellence is a page Toward Clinical Excellence: Learning from Experience. This page tells us that in September 2001 -

“The Sentinel Events Project Working Party members have been brought together from throughout the health sector to make recommendations to the Director-General of Health on the feasibility of implementing a mandatory event reporting system for health and disability services and related matters.”

The page links to their report that includes a number of recommendations. Here is Recommendation 3:

“Implement a national system (to be called the Sentinel Events Reporting System) that requires health and disability services to report a defined list of events (to be called Sentinel Events) to the Ministry of Health for review.”

The recommendation was made in September 2001. The initial report was published in February 2008. The data it published is neither accurate nor standard. Meantime, preventable death and harm occur. That’s a WOMBAT.

Seven years to get an incomplete report - how long to get some effective interventions?

And where do you find the Commentary On Sentinel & Serious Events Reported By District Health Boards - 2006/07 report? On the site of the Quality Improvement Committee - a sub-site within the Ministry of Health. Don’t bother trying to find it easily from the Ministry of Health website (it’s buried in there somewhere) - it also needs some quality improvement.

3 Responses to “Accidental hospital deaths plummet from estimated 750 to 40 actual”

  1. Peter Says:

    All goes to show, doesn’t it?

    Who was it that said something about lies, damned lies and statistics?

    Good post by the way

  2. No Wombats » Blog Archive » Confident it was an isolated case Says:

    [...] The Chief Medical Officer at Auckland Hospital claimed a case of preventable death had a combination of circumstances that was unusual and he was confident it was an isolated case. Sounds like code for “it won’t happen again because it’s very unlikely”. That’s not an effective way to deal with repetitive failure - and preventable hospital death in New Zealand is definitely a case of repetitive failure, the national solution to which has been to take seven years to produce an incomplete report. [...]

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