News Video | Policy | GPs | Hospitals | Medical | Mental Health | Welfare | Search


Unsterilised Equipment Used In Woman’s Surgery

Health and Disability Commissioner Morag McDowell today released a report finding Southern Cross Hospital Limited (SCHL) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of a woman undergoing orthopaedic surgery.

An unsterilised drill bit was used during the woman’s surgery at a Southern Cross Hospital, putting the woman at risk of infection and requiring her to undergo additional testing.

Prior to the surgery, the operating surgeon, who is not an SCHL employee, ordered equipment for the woman’s procedure from an equipment loan company. A representative of the loan equipment company was present in the operating theatre to offer assistance to the surgeon regarding the loan equipment.

After the woman had been anaesthetised it was discovered that the loan equipment delivered did not contain the specific equipment required for her surgery.

The company representative found a trolley of clean but unsterilised equipment and returned to the operating theatre and opened it. The company representative and SCHL staff did not check the equipment’s sterility before it was placed on the theatre’s sterile trolley. The surgery proceeded using the equipment.

Once the error was realised, the woman was required to stay longer in the hospital to monitor for infection. Although the surgeon communicated the error to the woman soon after surgery, a representative from SCHL management did not meet with her.

The Commissioner identified a number of factors that contributed to the private hospital’s systems failures in this case, including the way it stored unsterile instruments.

"The services provided to the woman were seriously inadequate and put the woman at risk of infection," said Ms McDowell.

"It was the private hospital’s responsibility to have processes and practices in place to ensure that the instruments brought into the operating theatre were confirmed as being sterile before being placed in the sterile operating field."

Ms McDowell also considered that the private hospital’s follow-up with the woman after the incident did not comply with its open disclosure guidelines.

She made a number of recommendations, including that SCHL undertake a full audit of all surgical equipment to ensure it has been sterilised and stored appropriately, and apologise to the woman.

She also recommended that SCHL engage with the equipment loan company to improve the process for sourcing loan equipment to ensure the correct equipment is supplied and can be easily checked off in advance of planned surgery.

The full report on case 18HDC1370 is available on the HDC website.

© Scoop Media

Culture Headlines | Health Headlines | Education Headlines


Howard Davis: Emerald Fennell's Promising Young Woman'

The Guardian needed not one, but three reviews to do justice to Fennell's unsettling approach, which indicates exactly how ambiguous and controversial its message really is. More>>

Howard Davis: Jill Trevelyan's Rita Angus

Although Angus has become one of Aotearoa’s best-loved painters, the story of her life remained little known and poorly understood before Jill Trevelyan's acclaimed and revelatory biography, which won the Non Fiction Award at the Montana New Zealand Book Awards in 2009, and has now been republished by Te Papa press. More>>

Howard Davis: The Back of the Painting

Painting conservators are the forensic pathologists of the art world. While they cannot bring their subjects back to life, they do provide fascinating insights into the precise circumstances of a painting's creation, its material authenticity, and constructive methodology. More>>

Howard Davis: Black Panthers on the Prowl

A passionate and gripping political drama from Shaka King, this is an informative and instructive tale of human frailty that centers around the charismatic Chicago Black Panther leader Fred Hampton, who was murdered at the age of twenty-one during a police raid. More>>

Howard Davis: Controlling the High Ground

Stephen Johnson's raw and angry film not only poses important questions with scrupulous authenticity, but also provides a timely reminder of the genocidal consequences of casual bigotry and xenophobia. More>>

Howard Davis: Dryzabone - Robert Conolly's The Dry

After the terrible devastation caused by last year’s bushfires, which prompted hundreds of Australians to shelter in the ocean to escape incineration and destroyed uncountable amounts of wildlife, The Dry has been released during a totally different kind of dry spell. More>>

Howard Davis: Hit the Road, Jack - Chloé Zhao's Nomadland

Nomadland is perhaps the ultimately 'road' movie as it follows a group of dispossessed and disenfranchised vagabonds who find a form of communal refuge in camp sites and trailer parks after the economic contraction of 2008. More>>



  • Wellington
  • Christchurch
  • Auckland