Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
Additional comments from the nurse
14.8 By letter the nurse added that there were several reasons why she would not
accept a verbal order:
“Dr Lucas could not/would not give me a dose. I was not familiar with
ergometrin as it was not routinely used and I wished to check it before
administering it. I had no witness to the order as was THL policy. It
was said in a very off-hand aggressive manner and I had very little
trust/faith that Dr Lucas would follow up the order with a written
prescription as per THL policy.”
In response to the suggestion that Dr Lucas was too busy to attend, the nurse
stated:
“Dr Lucas may have been too busy to attend the patient at that time. The
case he was anaesthetising was a long case and he made no attempt to
visit the patient at any time during her stay in recovery. Nor did he visit
her when the case (No 2) was completed. [The patient] was still in
recovery at this time.”
14.9 The nurse was asked to respond to the Group Manager (Hospital)’s
explanation that the surgeon was present in theatre. She noted: “The case
was over some time before I bleeped, the surgeon therefore would have left
theatre. When [the surgeon] did attend he was not in theatre attire and came
into recovery from the outside door.”
14.10 The nurse was asked about discrepancies between the incident report and the
evidence she gave at the interview. She commented that the letter
accompanying the incident report was only a short note and it was not
intended to be an in depth look at this incident. At the interview she had
been able to include more detail. In her subsequent letter she stated:
“I am unsure why I did not record that I asked Dr Lucas for fluids but
this incident was written on the day when I was angry at his lack of
support and therefore this may have been missed.”
Management response
14.11 The Group Manager (Hospital) said that he was aware of this incident:
“In the medication administration policy it states that, if there is a
medical emergency, verbal medication orders may be given and
followed. I understand that a nurse chose not to administer the
medication. I understand that the anaesthetist was busy at the time with
another patient when the recovery nurse sought the anaesthetist. The
anaesthetist gave her a verbal instruction to administer the medication
which the nurse refused to observe. I do not believe that a surgeon had
to come across from a ward as stated, but believe that the surgeon was in
theatre at the time.”
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