Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
recommendations. It is kept in the Outpatients Department …. They
were excellent and mostly appreciated by all of us.”
8.27 The same colleague also commented on Dr Lucas’ technical skills in relation
to interviewing and examining patients in the induction room before the
operation:
“I am also often there to see my patient before they go to sleep. I found
Dr Lucas very careful, precise and professional. He talked to the
patients and explained what was going to happen in great detail. He
spent quite a lot of time with patients and made them feel secure.”
Management response
8.28 The Clinical Director (Surgery) reviewed the incident form. He was also the
surgeon in the operation. He was irritated that a nurse new to theatre had
completed an incident form on this matter. He wrote on his investigation
report: “This is a totally unnecessary incident form. The staff who filled it in
should be disciplined and informed of when incident form completion is
appropriate.”
8.29 The Clinical Director (Surgery), in his written note to the investigation team,
explained that he thought it was “quite inappropriate for an inexperienced
nurse new to theatre to question a very experienced anaesthetist’s decision
regarding the administration of a particular drug”. However, the nurse’s
concern centered on the use of fentanyl without consent, not the usefulness of
fentanyl itself.
Audit report
8.30 The Gow/Gordon audit report commented:
“The comment about disciplining staff who fill out incident forms is
unacceptable, both in general terms and particularly with respect to this
incident. The Australian Council of Healthcare Standards’ Clinical
Indicator relating to drug allergy states that this is a sentinel event. In
this instance there is no documentation in the notes relating to this
discussion with the patient.
In addition, the giving of an anaesthetic without obtaining informed
consent, particularly at a time of vulnerability for the patient, is also
unacceptable practice.”
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