Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
12.5 A nurse stated: “One of the girls was quite upset when she saw him with
syringes in his pocket.”
Dr Lucas’ explanation
12.6 Dr Lucas described two scenarios where he might ask a nurse to administer
an unlabelled syringe:
“(1) Where for the sake of speed and patient safety a nurse would give
an IV injection in the presence of an anaesthetist who is already
doing something for the patient, eg maintaining an airway. In
that case I would ask the nurse while I watched to pick up the
5ml syringe off my cart and give 1 ml of its contents into that
injection site. The responsibility remained with me. I would ask
the nurse to be my second set of hands. I did not believe that it
was necessary for the nurse to know what was in the syringe, but
would tell them if they asked. A printed label on the syringe may
not be apparent to a nurse, but I am by no means the only
anaesthetist who implicitly labels my syringes by a combination
of syringe size and needle colour.
(2) Where I had drawn up a drug just before moving from theatre to
recovery. I would put the syringe in my shirt pocket. If after
arrival in the recovery room, the patient needed some or all of the
drug, and it happened that I was standing on the side of the
patient opposite the IV line I would give the syringe to a nurse
standing on the IV side and instruct them what volume to give.
Again, in that circumstance, I would not be asking the nurse to
take even a tiny amount of responsibility for the injection. If
there was drug left in the syringe I may tell the nurse what it is
and leave orders for its use. At that point it would become a
matter of trust between the nurse and me. If the nurse does not
trust me to tell the truth about what is in the syringe, they are
well within their rights to reject the syringe and draw up fresh
drug. However, if they didn’t trust me why would a label matter;
I could have mislabelled it.”
Management response
12.7 The Group Manager (Hospital) stated he was unaware of the unlabelled filled
syringes until Dr Lucas left THL and believes these were unreported
incidents.
Appropriate standards
12.8 There is no protocol for use of unlabelled filled syringes.
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