Steriliser that cleans surgical equipment in Hawke's Bay Hospital was never turned on, review finds
Originally published on Stuff
A broken switch, a broken printer, and a raft of human and systems errors were to blame for inadequately sterilised surgical equipment being used on patients in Hawke's Bay, reports have found.
The region's district health board on Wednesday released internal and external reports on the incident that saw the equipment used on up to 55 patients over nine days in February.
The reports found that staff who put the equipment in one of four sterilising machines, or autoclaves, at about 10.45pm on February 1 did not turn the machine on.
This may have been because the 'Start' button was not pressed, or because the button was known to frequently not engage.
Either way, the autoclave makes a loud beeping noise when it starts and staff should have ensured this occurred. They could not recall if they heard it.
The autoclaves are all connected to their own printers which signalled that the machines had been started and that they had been completed.
The printer on the machine in question had been broken for several months so no signal was given and no print out was available at completion.
Instead, staff had had to check on a computer to see if the machine had been operating.
On the morning of February 2 a different staff member removed the equipment from the autoclave, without adequately checking if it had been working.
The staff member did not check the computer to see if the equipment had been sterilised before dispatching the equipment for use in theatres.
The staff member also failed to check that sterilisation codes on the packages had not changed colour, indicating they had been sterilised.
Then clinical staff who were taking the equipment from their packs failed to check the colour codes before use.
It wasn't until February 11 that a nurse noticed one of the colour strips had not changed colour and the alarm was raised.
The external review found that all three sterilisation checks failed and that staff failed to follow sterilisation policy.
"The reviewers have concluded that there was a system wide failure across all departments to complete correct sterilisation checks," the reviewers said.
Since the incident occurred the start button and printer have been fixed and several changes to systems have been put in place.
The review found that sterile services nationwide had been ignored for "too long" and the Health Ministry should immediately put in place.
That included installing electronic tracking of each individual instrument and external auditing of all DHB sterilisation units.
The DHB's executive director provider services Colin Hutchison said the review "made it clear that no one person or department can be held accountable for this, as there were many errors across a number of systems and processes".
None of those patients on whom the instruments were used have shown any sign of infection, and the autoclave process was the last of a four stage sterilisation process so the chance of any infection risk was negligible.
Affected patients were to be tested for blood-borne viruses – including HIV and hepatitis B and C – but it would be 24 weeks following the incident before the patients could be given the all clear.