An action plan was put in place in the weeks after a Waikato District Health Board (DHB) surgeon performed an operation to remove the gall-bladder of a woman whose organ he had already removed 13 years before.
The plan gave Waikato DHB the opportunity to improve its processes and remind surgeons of their responsibilities, said chief medical advisor Dr Tom Watson today.
In releasing the plan, Dr Watson also extended his apologies to the woman and her family saying that he and the surgeon had met them regularly since the operation in June 2009.
“The family have supported our actions because they, like us, want to ensure nothing like this happens again,” he said.
Waikato DHB reported the case in its serious and sentinel event report released in November 2009. By then the root, cause, analysis panel had met.
Root cause analysis is a method used to investigate and analyse a serious or sentinel event to identify causes and contributing factors, and to recommend actions to prevent a recurrence.
“The process from there was one of learning and not blame.”
Waikato DHB sends out more than 28,000 clinical records per month for outpatient clinics, emergency departments, wards, queries, research and audits.
“We are embarking on a project to start scanning more information from clinical records into the electronic records but it will take many years,” said Dr Watson.
In addition, the DHB designed bright stickers to go on patients’ clinical records where it was an incomplete record.
The notice says that diagnostic results and some documents may only exist in the electronic record. It refers clinicians to the electronic clinical record.
- Serious Event action plan
- Preoperative investigations and surgical standards for laparoscopic cholecystectomy
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