Patients need to be informed

News that standards for sterility of surgical instruments were breached in five operations at Dunedin Hospital between March 31 last year and the end of January 2021 will be disquieting for anyone who had surgery in that time.

Nigel Millar
Nigel Millar
Southern District Health Board chief medical officer Nigel Millar has said the infection risk was "vanishingly small" but acknowledged it would be a matter of distress for patients.

There are still gaps in our knowledge about what occurred. The breaches of instrument sterilisation included surgical cement, hair and a water-filled connector being found on or within the instruments or the tray they were on once procedures started.

Cramped and inefficient working conditions for sterile services staff are cited as greatly contributing to recurring issues with instruments being improperly sterilised. There has been concern about the number of instrument trays which are rejected because they are not up to the standard required. In the six months to the end of January, the number of non-conformities recorded each week ranged from four to 39. Presumably, most of the breaches have been discovered by nurses or other staff before operations have commenced.

In March, the board’s hospital advisory committee was told about the work being done to mitigate the breaches before the move to a new sterile services facility in the Oncology building which it is hoped will be completed early next year.

But if we accept that the poor conditions for sterile services are a major factor, it is more difficult to see them as the only factor in this complex setting.

It is our understanding that once instruments are being assembled for an operation, pre-surgical check procedures are extensive, including visual inspections of equipment such as tubing to ensure nothing is inside it.

We wonder if short-staffing, inexperienced staff or gaps in education are contributing to this issue.

Despite Dr Millar’s acknowledgement of the distress for patients whose operations may have been affected, it seems unlikely any of the patients involved have been told, as the board has confirmed it has no documentation on this.

Yesterday, a spokesperson said the board was ‘‘working through this’’ but could give no further clarification. Did that mean the patients were going to be informed? Who knows?

It is not the first time SDHB has been found wanting on issues involving the sterilisation of instruments.

In two incidents which came to light in 2019, one involving congealed blood inside a surgical screwdriver and equipment exposed to air when it was incorrectly put together, the board did not inform the patients because analysis of the situation suggested they were not at risk. All the same, patients were reportedly monitored post-operatively for 30 days and checked at 90 days. No issues were found. If anything untoward had been found, and the board had to acknowledge what had happened at that late stage, how might the patients have felt about that?

The work chief executive Chris Fleming says is being undertaken to tighten processes and monitoring to mitigate the risks, including additional staffing, more education and additional steps to ensure greater checking and monitoring, is welcomed, but perhaps it is time for the board to revisit its position on open disclosure too.

The Health and Disability Commissioner’s guidance on this says that an error affecting the consumer’s care but which does not appear to have caused harm may need to be disclosed to the consumer, noting that the effects of an error may not be immediately apparent.

When errors are acknowledged swiftly and sensibly and patients are informed of what is being done to prevent such issues occurring again, patients are generally understanding and accepting. Anything less runs the risk of patronising patients and fostering suspicion and diminishing confidence in the hospital system, which is unfair to both patients and those dedicated to serving them.

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