Gisborne Hospital Report - Health and Disability Commissioner

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Page 4. Operating Theatre Protocols, October 1999 - June 2000 (continued) Fentanyl incident 101 Methods used to induce children 107 Mixing of opiates 113 Failure to document medication 114 Unlabelled syringes 118 Waking patients early and putting conscious patients in the lithotomy position 120 Refusal to attend patient in recovery 125 Incident reporting 130 Summary Opinion 132 5. PSA Testing Procedures, April 1998 - June 2000 Introduction 134 Prostate Specific Antigen (PSA) Testing 134 What went wrong? 139 Response of Tairawhiti Healthcare 148 Organisational, management and institutional factors 156 Problems of a small and isolated laboratory 162 Opinion 162 Recommendations 169 6. Patient Care in ICU and Surgery, April-May 2000 Introduction 173 How and why the nurse raised concerns with NZNO 174 Review of ICU patients’ files 175 Quality assurance in ICU 175 Opinion 177 Appendix 188 Glossary 193 ii
1. BACKGROUND EXECUTIVE SUMMARY 1.1 In June 2000, Gisborne Hospital became the focus of concerns about patient safety, after the New Zealand Nurses Organisation (NZNO) wrote to the Minister of Health and spoke to the media. The admitted re-use of syringes by visiting Canadian anaesthetist, Dr Brian Lucas, and the potential risk of disease transmission to patients, was widely published. 1.2 Alarm increased when Tairawhiti Healthcare Ltd (THL) announced in July 2000 that an error had occurred in Prostate Specific Antigen (PSA) testing at the Gisborne Hospital laboratory. Approximately 117 patients were notified of the error and advised to consult their general practitioners about the need for re-testing. 1.3 Against this background, I initiated an inquiry into patient care and quality assurance systems at Gisborne Hospital, with the following terms of reference: “As a result of allegations concerning standards of patient care and quality assurance systems at Gisborne Hospital, the Health and Disability Commissioner, Ron Paterson, is to commence an independent inquiry under section 35(2) of the Health and Disability Commissioner Act 1994. The following matters will be investigated to determine whether any action by Tairawhiti Healthcare Limited or any individual health care providers at Gisborne Hospital has breached patients’ rights under the Code of Health and Disability Services Consumers’ Rights: • Operating theatre protocols and compliance with such protocols between October 1999 and June 2000 • Quality assurance systems at Gisborne Hospital including incident reporting protocols and systems • The handling of incidents reported by staff between October 1999 and June 2000, including the issue of re-use of anaesthetic syringes • Allegations of inadequate standards of patient care in surgical and intensive care services in April and May 2000 • PSA testing procedures from April 1998 to June 2000.” 1.4 During the course of my inquiry, the Minister of Health dismissed the Board of THL in July 2000 and appointed Mr Wayne Brown as the interim Chairperson. The Chief Executive, Ms Sheryl Smail, resigned in October 2000, and was replaced by Mr Jim Green in December 2000. The investigation 1.5 An extensive investigation was undertaken from July through September 2000. Seventy-eight people were interviewed, including patients, staff, management, NZNO representatives, community organisation representatives, and members of the Maori community. The majority of
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RECOMMENDATIONS Quality Assurance S
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APPENDIX NZNO LETTER TO MINISTER OF
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11. The anaesthetist had a practice
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THE ANONYMOUS LETTER The anonymous
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GLOSSARY ABBREVIATIONS A&E A,T&R AQ
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Gisborne Hospital Report - Health and Disability Commissioner

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