An elderly Bay of Plenty patient fractured a hip after being pushed by a fellow patient who should have been in the geriatric mental health unit, a health report reveals.
Because there was no geriatric mental health bed available a patient whose behaviour was "characterised by acting out impulsively and provoked" was placed in an acute admission unit.
The incident is among 10 serious Bay of Plenty District Health Board cases, revealed in the annual serious and sentinel event reportfrom the Health Quality and Safety Commission.
The report, released yesterday, catalogues a litany of hospital botch-ups, clinical errors and near-misses nationwide - many resulting in serious injury and death.
All Bay of Plenty incidents relate to falls.
One patient from the region, who scaled a temporary fence and got on to the hospital roof, broke an ankle. Another whose pants fell down tripped on the way to the toilet and broke a hip.
One severely ill patient was transferred six times in 72 hours and fractured a hip after falling. Findings showed patient notes did not document that they had a high risk of falls.
Bay of Plenty DHB chief executive Phil Cammish acknowledged falls caused serious problems for patients and families.
"Along with the personal costs, there are financial costs to the health system.
"While we know not all events are preventable, it is important to us and our patients that we keep risk to a minimum in our hospitals."
Nationally, 360 serious and sentinel adverse events were reported in the 2011/12 financial year, down from 370 in the previous year.
Ninety-one resulted in patient deaths, compared to 86 in 2010/11.
Commission chairman Alan Merry stressed that not all reported events were preventable, but many involved errors which should not have happened.
"In some tragic cases, errors resulted in serious injury or death.
"Each event has a name, a face and a family, and we should view these incidents through their eyes."
Falls make up the bulk of serious and sentinel adverse events in hospitals - accounting for 47 per cent of all cases.
However, nine patients had surgical instruments or swabs left inside them and 10 others were given the wrong procedure or treatment.
There were also 18 reported mistakes with patient medication.
But a jump in clinical management errors, specifically those relating to treatment delays, is flagged as a concern.
Seventeen cases of delayed treatment because of failures in hospital systems were reported last year. But, the commission said, the actual number of incidents was likely to be much higher.
One patient in Auckland died after post-operative complications. A breakdown in communication between clinicians and a delay in recognising critical illness were blamed.
And a Wellington lung cancer patient died after test results were not followed up, delaying diagnosis and treatment.
Regional figures show 18 sentinel and serious adverse events were reported by the Taranaki DHB for the year. South Canterbury DHB recorded 17.
Reportable events clinical leader David Sage said the cases demonstrated how important it was for doctors to follow up.
"For example, making sure patients are full partners in the management of their care - so they too are aware if there needs to be a further test, result from a specimen or referral to another specialist."
The rise in clinical management errors, which make up nearly a third of serious and sentinel event, has also prompted calls for a review into district health board management systems by the commission.
Suspected suicides increased sharply, from three in 2010/11 to 17 in 2011/12. Three more have occurred since the end of the reporting period.
Professor Merry said there were no common factors in the each of the cases.
"There is no evidence of a trend of increasing in-patient suicides."
Serious adverse event: an event that leads to significant additional treatment. Not life threatening. No major loss of function resulted.
Sentinel adverse event: a life threatening event that has led to an unexpected death or major loss of function.
- Source: Health Quality and Safety Commission
Total serious and sentinel events:
Bay of Plenty DHB serious and sentinel events: