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A paperwork error by a specialist led to a woman having an unnecessary second colonoscopy.
An investigation by the Health and Disability Commission found the patient was told she needed an urgent colonoscopy just two days after the previous procedure showed normal results.
She left several messages for the referring specialist and also queried the reason for the extra procedure with the nurse on the day, but no one checked the paperwork.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell said an internal review carried out by the hospital found the referring specialist accidentally attached the wrong National Health Index number to the file.
However, there were several missed opportunities to correct the error and it was not until the procedure was under way that staff realised there had been a mistake.
"During the procedure, the specialist undertaking the colonoscopy (who was not the referring specialist) noted that the findings on the referral form were not consistent with what was being seen in the colonoscopy in real time.
"The specialist performing the procedure contacted the referring specialist and it was picked up that there had been an accidental mix-up of National Health Index (NHI) numbers.
"After the woman's sedation had worn off, the specialist informed her that there had been a mix-up with NHI numbers, resulting in her having an unnecessary colonoscopy."
Caldwell said she considered it "a serious incident" and Te Whatu Ora failed to provide services to the woman with reasonable care and skill.
The patient has already received a verbal apology from the referring specialist and a letter of apology from the hospital's clinical quality and risk manager.
Te Whatu Ora said it had already implemented the commission's recommendations, including keeping files separate to minimise the risk of an identification mix-up, and more checks and balances to pick up mistakes if they did happen.
