The importance of adequate supervision and training of
staff, and full disclosure of relevant information to people
using healthcare services was highlighted in a decision
published by Deputy Health and Disability Commissioner Dr
Vanessa Caldwell.
In her decision, Dr Caldwell found a
dermatology clinic in breach of the Code of Health and
Disability Services Consumers’ Rights (the Code) for
failing to provide services with reasonable care and
skill.
A woman was receiving narrowband UVB treatment
(a form of phototherapy used to treat skin diseases), for
her psoriasis from a dermatologist at a dermatology clinic.
She had attended eight sessions with a slowly increasing
dosage with no adverse reactions. On her ninth session,
staff mistakenly entered the incorrect name into the system,
and the woman received a longer session than expected. This
led to the woman receiving a significantly higher dose of
narrowband UVB, resulting in burns across her body. On
advising the clinic of these burns she was not given advice
regarding treatment and instead was advised that a doctor
would be available in a couple of days. The woman later
presented to the Emergency Department and was treated for
pain and burns. The clinic failed to inform the woman about
its investigation into the error, and did not tell her about
the cause of the error.
Dr Caldwell concluded the
clinic’s failure to supervise and train staff adequately
led to the initial error, as well as their inappropriate
actions afterwards, and therefore found them in breach of
the Code
“Staff need adequate support and training to
enable them to provide appropriate advice to patients in the
case of an adverse event, and to have in place a clear line
of escalation so patients can receive appropriate follow-up
care.
“I consider staff at the clinic were not
supported or trained in their role adequately to provide
safe care. As a result, the woman was given another
patient’s dose, and was not provided with medical advice
on how to treat her resulting redness and burns,” says Dr
Caldwell.
Dr Caldwell also made adverse comment about
the clinic’s failure to disclose to the woman, its
investigation into the event and the cause of the
error.
“When provision of a health service is not as
expected, it is understandable for people to have questions
and to seek a clear explanation of what went wrong.
“I
am critical of the clinic for failing to investigate the
cause of the machine error, for not informing the woman of
either the cause of the event, or the outcome of the
investigation in a timely manner, and for failing to
apologise to her in a timely manner,” says Dr
Caldwell.
Following the events of this case, the
clinic reviewed its protocols and made multiple changes to
its processes and procedures to reduce the likelihood of a
similar error occurring. This included implementing checks
and restricted permissions on the UVB computer to ensure
errors are not made.
After taking into account the
improvements made to their service, Dr Caldwell further
recommended the clinic ensure the individuals involved
provide a written apology to the woman; develop a
comprehensive policy for adverse events; provide its
reception staff with first aid training, and training on
managing an adverse event; amend the UVB set-up policy to
include a more comprehensive double-checking protocol; and
develop an open disclosure policy to ensure that patients
are kept up to date with the status of internal
investigations and the changes made as a
result.
“Internal review of any adverse event is vital
to ensure changes are made to prevent a similar event from
occurring. I acknowledge the clinic has taken this issue
seriously and commend them on the improvements made to their
service,” says Dr Caldwell.
Editors
notes
The full
report of this case will be available on HDC’s website.
Names have been removed from the report to protect privacy
of the individuals involved in this case.
The
Commissioner will usually name providers and public
hospitals found in breach of the Code, unless it would not
be in the public interest, or would unfairly compromise the
privacy interests of an individual provider or a
consumer.
More information for the media and HDC’s
naming policy can be found on our website here.
HDC
promotes and protects the rights of people using health and
disability services as set out in the Code
of Health and Disability Services Consumers’ Rights (the
Code).
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