National learnings from external review of Hawke’s Bay sterilisation incident

Findings from the external review of the sterilisation incident at Hawke’s Bay Hospital in February has highlighted national learnings and process errors.

Executive director provider services Colin Hutchison said the external review had followed a robust and independent process to establish what had led to one batch of unsterilised equipment being used in Hawke’s Bay Hospitals’ theatres and outpatients clinics, without the proper checks and balances followed.

Dr Hutchison said the investigation highlighted a series of issues that began at the steriliser stage which included; not confirming the steriliser had begun its cycle, cross-checking safety processes and colour changes on equipment pouches that went undetected at all stages.

 “The review has 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.

“While we are pleased the reviewers commended the district health board for its open disclosure of the event, many of the issues would not have occurred if policies and processes had been embedded.

“We have caused distress to the patients affected and we apologise to those people for the anxiety this has caused.”

Since the event Hawke’s Bay DHB immediately instigated a number of changes including; making tape on small pouches much larger so the change in colour couldn’t be missed, replacing a printer and delaying moving into a paperless environment until checks were well embedded.

The DHB will work towards appointing an educator specifically to sterile technician training and professional development as well as system-wide retraining to ensure clinical staff understood and followed all steps and protocols regarding the handling of sterile equipment.

Alongside this the district health board was also in the process of upgrading its electronic tracking system of reusable medical devices, which was due to be completed this month. 

Dr Hutchison said the reviewers had recommended electronic tracking and traceability systems be installed at all sterile units and operating theatres throughout the country as soon as possible, with tracking identifiable to individual instrument level.

The reviewers had also called for this tracking system to be extended out to include all wards and outpatient clinics within 18 months. They have also made national recommendations that sterile services should undergo external auditing in conjunction with robust internal auditing.

“I’d like to thank the many people involved in the review processes, and our staff who have helped support the reviewers by providing information in a free and frank way so learnings both locally and nationally can be made.”

The full external report can be found here.

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