Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
“In our interviews with anaesthetic technicians they confirmed that you
had a particular preference for intravenous fluids and that the usual
practice was to give IV fluids during the anaesthetic. There was general
agreement that, if an IV line was in place, you would have used the
injection port on the line to administer any agent.
The technicians commented that there would have been a small number
of cases where there would not have been an IV line. MUA was one
category. In that situation you would have given agents through the
cannula.
In your reply you indicated that the number of cases where an IV line
was not in place would have been very small. You accepted, however,
that there were some. You commented that the type of case where it
might happen were very unlikely to have been part of a routine list. For
such cases your practice would have been not to re-use syringes from
such cases. This was because the syringes were used in such proximity
to the patient and would have presented a risk to subsequent patients and
in those cases [you] would discard the syringes after use.”
Explanations of re-use
3.7 Dr Lucas described his re-use of syringes as a habit of over 20 years. It was
suspected by anaesthetic technicians and theatre nurses that subsequently Dr
Lucas re-used syringes intentionally, in order to save money for the hospital.
The Head of Department (Anaesthesia) gave as an explanation that “Dr Lucas
came from Canada. In Canada they do not have a set written standard not to
re-use a syringe.”
Staff observations of re-use
3.8 Dr Lucas admitted to the occasional lapse in re-using syringes after being told
it was not acceptable practice at THL. A few staff (one nurse and two
technicians) saw him re-use on isolated occasions, but it was suspected he reused
more frequently than that. Apparently, in order to pre-empt this,
technicians began to throw out syringes between patients, but Dr Lucas was
not happy about that and told at least one technician not to do so.
3.9 Two of the surgeons interviewed by the investigation team reported that they
did not see Dr Lucas re-use syringes. A locum surgeon reported never seeing
Dr Lucas re-use syringes and not being aware of any conflicts about the re-use
of syringes until he read about it in the newspaper. He asked other surgeons
and some of the anaesthetists whether they had seen Dr Lucas re-using
syringes. “They only heard, but never actually saw it for themselves.” Two
anaesthetic technicians never saw Dr Lucas re-use or refill syringes.
3.10 The Head of Department (Anaesthesia) stated that only two of the six
anaesthetic technicians saw Dr Lucas re-use syringes. He confirmed that
given “anaesthetic technicians are there all the time, they would have seen it
had Dr Lucas been constantly re-using syringes”. A surgeon reported a doubt
that anyone witnessed Dr Lucas re-using syringes.
75