medical misadventure - I have undertaken many misadventure cases and most occur as a result of several people making an error.  There needs a far greater emphasis in risk management.  You have infection control nurses but not risk management ones.  Whilst everyone is responsible for risk management like infection control you also need someone who is specalised to  ascertain risks, are you triage systems understood, are your grounds safe for high risk clients, are your staff adequately trained.    As an illustration there was a assessment ward started without tirage system being in place so everyone had a different idea, that should never happen.  The head medical officer had an extensive job description but it did not include risk management.   Other issues such as a Dr being so unplesant the nurse did not tell him that she was concerned with what she saw on ECG.  To a large extent you need a culture of excellence and good communciation and a culture where drs and nurses work to stop errors being made.  I think one unfortunate thing about ACC is that hospitals do not spend as much time avoiding error as they do in America, in America they have to reduce errors else they will be sued.  I have also undertaken post graduate medical ethics papers, am a nurse, barrister and standing to improve quality.  its not to late to vote would love your number one ranking as I am standing independantly 

Alison,

I trust that your son is now on the way to recovery.

Over the past 15 years there has been considerable progress in the the management of iactogenic risk, that is the risks that occur becuse of how health professionals practice and how the systems they work in are managed. The Health Practitioners Competency Assurance Act has done much to assure that public that health professionals are safe to practice; this is done through the regulatory authorities for each professional. I sit as a health professional on the NZ Council of Midwives.

Secondly, each DHB is charged with establishing systems and processes to ensure that the best care can be carried out in the most cost efficient manner. The best way is establish from experience. I am keen to see formal systems established to retain institutional knowledge and apply that to changing the processes in our clinical environments.

Also, the most recent research on misadventure was undertaken by Dr Peter Davis and others. Approximately 8% of hospital admissions have some activity which causes harm (some are very minor). The number of deaths as a direct result of harm is very small and all are examined in depth through the Health and Disabiility Commissioners Office and the professional regulatory authorities described above.

Dr Lee Mathias

DHSc, MBA, BA, RN

I am sorry you have had such an unfortunate experience .My own with Neurology services has been excellent .

When errors or mistakes happen a full review --often by the H&D C Office will identify errors and ommissions and identify corrective action to prevent future events . It is important consumers bring errors/complaints to staff attention so changes can be made.But I agree coordination between services or clinics is problematic and you will note it is one of my top concerns.

Best wishes with your journey through the health system.

With Kind Regards

Robyn Northey