Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
assure them management had heard and was taking their complaints
seriously.”
3.29 The second inquiry was an internal audit conducted by Dr Peter Gow
(Chairman of the Clinical Board, South Auckland Health) and Mary Gordon
(Director of Nursing Practice, South Auckland Health). The Gow/Gordon
audit report, dated 22 September 2000, recommended:
“A more formal procedure to acknowledge receipt of incident forms to
the quality co-ordinator needs to be in place. A copy of the incident
form needs to be kept in the service area from which the report has
come. This would then allow an audit by the service of the action
which results from the reporting of incidents. The incident reporting
system needs to be accompanied by an educational process, which could
be enhanced by details of the protocols for reporting being attached to
the incident form booklet.”
Appropriate standards
3.30 Following problems in both Melbourne and Whangarei of syringe re-use by an
anaesthetist, the Council of the Australian and New Zealand College of
Anaesthetists agreed upon a clarification and expansion of the College’s
“Policy on Infection Control P28” (1995). This recommendation was issued in
May 2000 (after Dr Lucas’ departure from Gisborne).
3.31 The text of this recommendation is:
“Recommendation of Re-use of ‘Single Use’ Equipment for Invasive
Procedures – May 2000
The labelling of products as ‘single use’ is an indication by the
manufacturer that the product is either unable to be re-sterilised or its
safe function may be compromised by the re-sterilisation process.
As sterilisation is required for the apparatus that will be used for any
invasive procedure (eg intravenous access, regional anaesthesia and
invasive monitoring), such apparatus labelled ‘single-use’ must not be
reused. This includes all apparatus that is in continuity with the vascular
system.”
3.32 As Dr Alan McKenzie, Deputy Chairman of the New Zealand National
Committee of the Australian and New Zealand College of Anaesthetists, made
clear to Dr Peter Schaap of Gisborne Hospital in a letter dated 13 June 2000,
this recommendation “makes perfectly clear that re-use of ‘single-use’ devices
for invasive procedures or accessing the vascular system of patients is not an
acceptable practice”. The recommendation was sent to the Chief Executives
of all surgical hospitals and to all doctors identifying anaesthesia as an area of
practice in information supplied to the Medical Council of New Zealand.
3.33 Before this recommendation was issued the position of the College on the reuse
of “single use” equipment for invasive procedures had not been explicit
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