New Zealand: Poor hospital discharges blamed for three deaths
Patient Safety Monitor: Global Edition, December 23, 2008
New Zealand Health and Disability Commissioner Ron Paterson issued five decisions concerning sentinel events, blaming them on hospital system errors, reports the Dominion Post.
Paterson says the events, which occurred in different hospitals throughout the country, were caused in part because old paper methods of tracking patient information do not work in the country's overcrowded emergency departments. The events included a deathly infection after discharge, a number of missed fatal head injuries, and failed detection of a blood disorder in a baby, who later died, according to the Post.
Some of the hospitals involved have since implemented electronic tracking systems and stricter staffing levels.
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