Source: The Conversation (Au and NZ)
At this time of year, crowded hospital emergency departments are a familiar sight around New Zealand. It’s also a symptom of a health system under intense pressure.
For patients, it means long waiting times to see a doctor. But for clinicians balancing workforce shortages with rising demand, it can mean making increasingly difficult decisions in far from ideal circumstances.
Such pressures, which can raise the risk of clinical error, have prompted the New Zealand Nurses Organisation to campaign for enforceable safe staffing levels.
A recently released finding from the Health and Disability Commission (HDC) provides an unfortunate example. It involved a 55-year-old man who presented to an ED – at the time operating at 200% occupancy and ten nurses short – with burning central chest pain.
The triage nurse assessed the pain as non-cardiac and assigned a triage score requiring assessment within 30 minutes. But an ECG was not performed until four-and-a-half hours later, when it confirmed he was having a heart attack, before being urgently referred to the hospital’s cardiac team.
Health NZ’s subsequent adverse event review concluded the patient should have been assigned a more urgent triage category. Its recommendations included more education for triage nurses, escalation procedures for when ED capacity becomes critical, increased staffing and a waiting-room nurse.
“”Next paragraph rearranged”“
The HDC investigation found Health NZ had breached the Code of Health and Disability Services Consumers’ Rights.Its findings, reported in national news media however, reached a different emphasis. While acknowledging hindsight bias and pressure on nursing resources, it focused on the failure to recognise the patient’s symptoms as cardiac, assign the correct triage score and ensure timely assessment.
Clearly, the patient should not have waited that long for treatment. But this case illustrates how difficult it can be to disentangle individual clinical judgement from the pressures of the system in which it is made.
When triage is tested
That distinction is particularly difficult in ED triage, where nurses must make rapid judgements about which patients need the most urgent care.
On the basis of a patient’s history alone, it can be difficult to distinguish cardiac pain from less serious conditions such as indigestion.
Patients may also describe their symptoms differently – some emphasising their severity in the hope of being seen sooner, others downplaying them in the hope they are not seriously ill.
The consequences are magnified when an ED is overcrowded. Had the patient been assessed within the 30-minute timeframe attached to his original triage category, the misclassification ”“would”“ not have resulted in such a lengthy delay in diagnosis and treatment.
But requiring nurses to spend longer on every triage assessment could further slow an already overwhelmed ED.
Another response is “defensive triage”, where nurses routinely assign patients more urgent categories to minimise the risk of getting it wrong. Neither addresses the underlying problem of too many patients and too few staff.
There is also a potential cost for clinicians when things go wrong.
Research involving 13 New Zealand doctors, nurses and midwives subject to HDC complaints found investigations could have profound and long-lasting effects on their wellbeing, professional identity and willingness to continue practising.
This has been described as the “second victim” phenomenon: the harm experienced by patients remains paramount, but clinicians involved in adverse events can also experience significant impacts.
A changing approach
None of this means clinicians should not be held accountable when patients are harmed. But it’s worth considering whether New Zealand’s system for investigating complaints has kept pace with changing approaches to patient safety.
When the HDC was established in 1996, there were no public standards of care and quality improvement was not yet an established discipline. Its rights-based approach represented a significant advance on what came before.
The health oversight environment has changed considerably since then. The establishment of the Health Quality & Safety Commission brought a greater focus on understanding why adverse events occur and using them to improve the wider health system.
That approach is reflected in the National Adverse Events Policy, which emphasises “healing, learning and improvement”, alongside system accountability and learning. Drawing on restorative principles, it calls for patients, whānau and healthcare workers involved in adverse events to be listened to, supported and treated fairly.
In this case, Health NZ’s adverse event review broadly followed that approach.“”It met with the patient”“,it identified the incorrect triage category, but its recommendations focused on preventing a recurrence through system improvements in the hospital.
The HDC process operates differently. While it also considered system pressures and recommended improvements, investigations are generally based on clinical records and written accounts, rather than meetings between the complainant, clinicians and others involved.
Here, the final decision was released three years after the event. It is debatable whether such lengthy investigations serve either patients seeking resolution or clinicians involved in them.
There is also potential overlap between the two systems. Health NZ had already conducted an adverse event review and recommended changes before the HDC reached its findings and made further recommendations. This raises the question of whether their respective roles could be better aligned.
A more restorative approach to complaints would shift the emphasis from identifying a breach and who was responsible towards understanding what happened, the harm caused and what is needed to prevent it happening again.
That would not remove accountability. But it could allow accountability to sit alongside the system-focused approach New Zealand already takes to improving patient safety.
Ben Gray does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
Original source: https://analysis1.mil-osi.com/2026/08/20/when-an-overloaded-ed-gets-it-wrong-who-should-be-accountable/