3 Sep 2023

Two patients had parts of their skull dropped in surgery - which were sterilised and put back in

6:54 pm on 3 September 2023

By Hannah Martin of Stuff

An ECG (electrocardiogram) in a hospital surgery operating room.

File photo. Photo: 123rf/ Georgiy Datsenko

Parts of patients' skulls were dropped mid-operation - which were then sterilised and put back in place - in separate incidents at the same hospital over the past five years.

Capital, Coast and Hutt Valley health districts recorded the incidents at Wellington Hospital operating theatres - one in 2018 and the other in 2022.

Data obtained under the Official Information Act (OIA) shows they're among a handful of similar incidents of body parts dropping in surgery reported by health districts in the past five years.

In April Stuff reported that a man's donor heart was dropped on the floor during transplant surgery.

The man, identified only as John H, died from septic shock at the age of 61, weeks after having a heart transplant: the cause of death was an infection due to a condition inherited from the donor.

Coroner Debra Bell​ said an investigation by the Health and Disability Commissioner (HDC) found dropping the heart didn't directly contribute to John H's death, and Bell determined the incident wasn't for her inquiry.

In the Wellington Hospital incidents, there was no adverse outcome for either patient, the OIA response stated.

There was one reported incident where "an organ or body tissue was dropped" during a procedure at Southern district in the past five years.

The health board reported "no adverse outcome".

Te Whatu Ora Waikato also identified in incident in the past five calendar years where "body tissue was dropped" during a procedure.

"Immediate corrective action was taken", it said.

After "appropriate preparation" the body tissue was able to be used for the procedure as planned.

They did not elaborate on the type of tissue or year in which the event occurred, citing privacy.

Te Whatu Ora's David Bunting​ said having a "strong culture" of open disclosure and reporting of serious adverse events across the health system has a number of important benefits.

This included encouraging and supporting self-learning from analysing reportable events; promoting the redesign of systems as the main methods for improving safety; supporting a culture where every health care worker takes personal responsibility for patient safety; and creating an environment where discovering and reporting problems and mistakes is not punished.

Serious adverse events - such as the dropping of organs or body tissue during a procedure - continue to be reviewed individually through formal processes at a local level and are reported on nationally within Te Whatu Ora, Bunting said.

"Our patients are at the centre of everything we do. We are committed to openly and honestly discussing adverse events that occur during health care as well as preventing these events from happening again."

Te Tāhū Hauora Health Quality & Safety Commission received 1137​ adverse event reports between July 1, 2021 and June 30, 2022 - up from 1027​ in 2020/21.

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