Patient care and quality assurance systems

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.