Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
PSA Testing Procedures
benefit in producing the data. Mr Rutledge noted that the process for quality
control in microbiology is different from that required in biochemistry. THL
also thought that the transfer of data into the QC Reporter programme was of
no benefit.
3.26 THL denied that the biochemistry section was short staffed over this period,
contrary to what Mr Rutledge said. THL said:
“Currently [the section is] being run with the same staffing as was
employed immediately prior to John Rutledge’s departure and all quality
controls are in place and functioning with excellent results.”
3.27 Commenting on this section in the provisional opinion, THL said:
“The AXSYM and Beckman analysers do have on board quality control
data management systems. We believe that all hospital laboratories use
the ‘on board’ systems. This is less labour intensive and more accurate
through eliminating transposition errors. The AXSYM analyser did not
have the quality control options set up and therefore could not reject
erroneous results. This is a parameter that should be set by the operator
…. [Gisborne Hospital Laboratory] was the only laboratory we are
aware of that failed to set up the analyser to review patient results. The
associated printer was found to be disconnected and configured
inappropriately for use on the analyser. Subsequent quality control
results pinpoint exactly when there was a problem. Everything was not
within limits.”
External system
3.28 The external AQAP programme was run by the Royal College of Pathologists
of Australasia for general chemistry using the Beckman analyser. On the
AxSYM, the programme was run for therapeutic drugs – phenytoin and
digoxin - as well as for Human Chorionic Gonadotropin (pregnancy test or
HCG). No AQAP external control samples were run by THL on PSA test
results because THL allegedly considered this part of the external control
programme to be too expensive.
3.29 THL denied this was the case. It stated: “PSA testing was part of the send
away testing programme, and samples were forwarded to Canterbury Health
and Medlab South for analysis until John Rutledge on his own behalf
recommended the testing in house.”
QC Reporter 2.0 software programme
3.30 Mr Rutledge noted that to keep up with current standards of care he had
introduced to the laboratory a software programme - QC Reporter 2.0 - to
manage the data obtained from using controls. It was a quality control system
independent of the ‘on board’ analyser QC programmes, and was used for
statistical purposes and to pick up trends or variations over a longer term than
that produced each day by the ‘on board’ analysers.
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