Hospital steriliser was never on
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 yesterday released internal and external reports on the incident in which the equipment was 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, about 10.45pm on February 1 did not turn it on.
This may have been because the Start button was not pressed, or because the button was known to frequently not work.
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 were all connected to their own printers which signal that the machines have been started and when the cycle has 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. Instead, staff 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 it for use.
The staff member also failed to check that sterilisation codes on packages had changed colour, which would indicate they had been sterilised.
Clinical staff later taking the equipment from their packs also failed to check the colour codes.
It wasn’t until February 11 that a nurse raised the alarm. The external review found that all three sterilisation checks failed and that staff failed to follow sterilisation policy.
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 changes, including electronic tracking of each 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 could be held accountable as there were ‘‘many errors across a number of systems and processes’’.
None of the patients has shown any signs of infection, and the autoclave was part of a fourstage sterilisation so the chance of infection was negligible.