Wrong sperm among medical mishaps

  • NZ report finds 374 public hospital mishaps
  • Mishaps include 127 deaths
  • Figures up from 308 last year with 92 deaths

A WOMAN inseminated with the wrong sperm, a new mother placed in scalding water, and a patient given radiation therapy by mistake.

These are among the 374 medical mishaps that befell patients in New Zealand’s public hospitals in the 12 months to June 2010. A report, released today, has found errors in public hospitals resulted in 127 preventable deaths.

The number of “serious and sentinel” incidents had risen from 308 the year before, leading to 92 deaths, the Health Quality and Safety Commission (HQSC) in NZ said. The commission defines a sentinel event as one that is life threatening or has led to an unexpected death or permanent major disability.

A serious event was defined as one that requires extra treatment but was not life threatening. Of the 127 people that died during admissions or shortly afterwards this year, half took their own lives. HQSC chairman Alan Merry said the rise in figures was expected with more vigilant reporting.

“The human cost of these events is too high,” Prof Merry said. “While we cannot go back in time and prevent particular events … we can, and must, learn from them and reduce the likelihood of this kind of avoidable harm in the future.”

Reports of serious and sentinel events have been released in NZ since 2007. The report, compiled using data from District Health Boards around NZ, documented the errors and steps taken to correct procedures.  Among them, a woman in inseminated with the wrong sperm after an unused sperm container was not discarded. No pregnancy resulted from the error.

A patient was sent home with a surgical swab inside them – not discovered until five days after the operation. Radiation therapy was given to a patient unnecessarily after their test results were interpreted wrongly. Three patients had to undergo second eye operations after cotton fibres were found under their synthetic eye lenses following cataract surgery.

A new mother sustained burns to her buttocks and perineum when she was placed in scalding water after the birth of her baby. She was given the hot bath to help her pass urine, but midwives have now been told to stop the procedure.

A patient died after inhaling their stomach contents when a naso-gastric tube was not inserted before they were anaesthetised.

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