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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.

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