Patient died on dialysis

[okarol]

Patient died on dialysis
ADRIAN EVANS
Last updated 07:24 27/11/2012

A dialysis patient bled to death in a community dialysis home after an alarm failed to activate because there was only one phone line into the house.

That death was one of 25 unexpected and preventable cases where patients came to harm or died in Counties Manukau District Health Board facilities in the past year. The number is down from 35 the previous year.

The figures were released in the 2011-2012 Serious and Sentinel Events Report from the Health Quality and Safety Commission.

The report shows 360 serious and sentinel events were reported nationally, 3 per cent fewer than the 370 recorded in 2010-2011. It also found that 91 patients died but not necessarily as a result of the event.

Commission chairman Professor Alan Merry says not all the events described in the report were preventable but many involved errors that 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."

Auckland District Health Board recorded 62 serious and sentinel events, Waitemata 29 and Waikato 26.

Counties Manukau Health chief medical officer Dr Gloria Johnson says there is still room for improvement in the board's statistics despite the drop in cases.

"The actual rate is not the important thing and we wouldn't feel pleased about that. A drop in the rate doesn't make us think ‘oh we're making progress'."

Five other patients died while in Counties Manukau Health care - the suicide of a mental health patient, a stillborn baby who died after complications at birth and three deaths from falls.

Serious events included a patient who needed a second operation after it was found that tubing had been left inside after a bowel operation four days earlier.

Dr Johnson says all cases were investigated to ensure errors were not repeated and the board continues to look at reducing the number of falls which made up 78 per cent of the cases.

"All hospitals grapple with these problems, partly because we're so busy.

"We try and look at all the different factors that have contributed to the error.

"The sort of things we're especially keen to improve on is when it's been a communication breakdown in our systems."

http://www.stuff.co.nz/auckland/local-news/manukau-courier/8001742/Patient-died-on-dialysis

[babycake]

we had a elderly lady a few yrs back
at my center i guess she had not been feeling good
and she had no insurance.. davita pays for her treatments

she went into cardiac arrest
and she was in the hospitol
for maybe 2weeks if that

she still comes in the center
and hasent had any issue
that i know of any how


her grandkids used to come all the time to visit
that day she had that issue her grandson
had just walked out of the room

[Rerun]

Davita doesn't pay for her treatment.  We all have Medicare unless we are illegals. 

[babycake]

Davita doesn't pay for her treatment.  We all have Medicare unless we are illegals.

thats right

and davita takes over the payment