Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Incident Reporting and Complaints Procedure
4.5 There seemed to be no consistency about when senior management was
informed about incidents. The Chief Executive stated that “there is no
formalised policy in place on what clinical events should raise a red flag with
the Senior Management Group”. A senior manager stated that “there were no
hard and fast rules about identifying incidents I considered critical. However,
my rule of thumb was that: if there was a significant patient, legal, financial,
reputational or regulatory risk then the CEO would be informed”. It is
unlikely that all staff had this level of insight.
Review of individual incident reports
4.6 The report of an expert group on learning from adverse events in the British
National Health Service entitled An Organisation with a Memory (Department
of Health, UK, 2000) concluded that analysis of failures needs to look at root
causes, not just the proximal events (p 46). Human errors cannot be sensibly
considered in isolation of wider processes and systems.
4.7 This view is congruent with the THL Incident and Complaint Management
Policy which states (point 9, p 2) that the review of complaints and incidents
should include “root cause identification”. Despite the lipservice to this
concept, its application in practice was not apparent in the review of incidents
analysed by the investigation team.
4.8 This failure is illustrated by an incident report that identified that a staff nurse
connected an intravenous infusion at the rate for a 12-hour infusion when it
was intended to be administered over 24 hours. The staff nurse reported the
incident two hours after it occurred. A senior nurse reviewed this incident. The
focus of the review was on the medication error. Language used in the
documentation of the review was punitive and blaming. There is no evidence
in the typed incident review that the conditions in which the incident occurred
were considered.
4.9 The reporting nurse’s account of the incident, which was recorded on the
incident form and available to the incident reviewer at the time of the review,
provides the following information:
• the nurse had had no meal break or drink for over seven hours
immediately prior to the incident occurring
• there was 10 minutes’ notice of the patient’s admission and the patient
required ventilation
• there were no spare beds in the area
• an emergency arrest in the Accident and Emergency Department
required attention during this time
• there were four staff on duty in ICU and two CCU patients and four
ICU patients (two of whom were ventilated).
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