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Patient care and quality assurance systems (Gisborne Hospital Report)

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(Gisborne Hospital Report, March 2001)


Public hospital ~ Operating theatre protocols ~ Standard of care and co-ordination ~ Quality assurance systems ~ Incident reporting and complaints procedure ~ PSA testing procedures ~ Refusal of consent to anaesthesia ~  Rights 4(1), 4(2), 4(4), 4(5), 7(7), 10(6)

In June 2000, the New Zealand Nurses Organisation wrote to the Minister of Health and contacted the media about concerns of nurses employed at a small, provincial public hospital. The admitted re-use of syringes by a visiting anaesthetist and the potential risk of disease transmission to 134 surgical patients were widely published. In July 2000, the hospital announced that an error had been made by its laboratory in carrying out prostate specific antigen (PSA) testing. One hundred and seventeen patients were notified of the error and advised to see their general practitioner about the need for re-testing. Against this background, the Commissioner initiated an inquiry into patient care and quality assurance systems at the hospital. The subsequent report found specific breaches of the Code in the operating theatre (due to the re-use of syringes) and in the laboratory (due to failures of quality control and human error in relation to PSA test results). The Commissioner also found breaches of the duties of care and co-ordination by the hospital provider, due to the failure to have adequate quality assurance and incident reporting systems in place.

Quality and continuity of patient care was potentially compromised by the lack of an effective incident reporting system. The hospital's complaints procedure did not inform patients of relevant internal and external complaints procedures, in breach of Right 10(6) of the Code.

An anaesthetist inappropriately re-used syringes, failed to dispose of sharp instruments in accordance with theatre protocol, and administered anaesthesia (fentanyl) despite a patient's specific refusal of consent. These acts by the anaesthetist constituted breaches of Rights 4(4), 4(2) and 7(7) respectively.

The Commissioner's report included 34 recommendations related to incident reporting and complaints handling, recognising that analysis of adverse events in health care should focus on root causes, and not simply the proximal events or human errors in isolation of wider processes and systems. The Ministry of Health subsequently audited the hospital and confirmed that the recommendations had been implemented. The report was distributed widely and is being used by other public hospitals in New Zealand to improve the quality of care.

Several general points are worthy of note. First, if reported incidents are not investigated and reported back on, complainants feel disenfranchised and not valued, and an environment of distrust and poor confidence will result. To prevent this, there needs to be a culture of learning, not blame. Extending reporting to cover "near misses" reflects a focus on prevention and improvement, rather than on finger-pointing and recrimination; on teamwork, rather than individual culpability.

Secondly, care needs to be taken that any emphasis or focus given to a single safety or accreditation issue does not undermine a general culture of safety and excellence. Long-term goals and practices need to be protected from possible inadvertent harm caused by pursuing short-term goals.

Thirdly, staffing levels should be sufficient not only to cover the daily workload but also to allow staff to undergo continuing practical training sessions, attend regular section meetings, attend user group meetings to discuss quality issues, keep documentation and quality manuals up to date, and carry out any other activities that contribute to improving and maintaining quality.


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