Process improvements made to dermatology clinic following error in woman’s UVB treatment


The importance of adequate supervision and training of staff and full disclosure of relevant information to people using health services has been highlighted in a decision issued by the Deputy Commissioner for Health and Disability, Dr Vanessa Caldwell.

In her decision, Dr. Caldwell found that a dermatology clinic violated the Health and Disability Services Consumer Rights Code (the Code) for failing to provide services with due care and skill. reasonable.

A woman was receiving narrowband UVB treatment (a form of phototherapy used to treat skin conditions) for her psoriasis from a dermatologist at a dermatology clinic. She had attended eight sessions with a slowly increasing dose with no adverse effects. During her ninth session, staff mistakenly entered the incorrect name into the system, and the woman had a longer session than expected. This led to the woman receiving a significantly higher dose of narrowband UVB, resulting in burns all over her body. When she informed the clinic of these burns, she was not given any advice regarding treatment and was instead informed that a doctor would be available within a few days. The woman then presented to the emergency department and was treated for pain and burning. The clinic did not inform the woman of its investigation of the error and did not tell her the cause of the error.

Dr. Caldwell concluded that the clinic’s failure to adequately supervise and train staff led to the initial error, as well as their subsequent improper actions, and therefore found them to be in violation of the Code. .

“Staff need adequate support and training to enable them to provide appropriate counseling to patients in the event of an adverse event and to put in place a clear line of escalation so that patients can receive care. appropriate follow-up.

“I consider that the clinic staff were not sufficiently supported or trained in their role to provide safe care. As a result, the woman received the dose from another patient and did not receive any medical advice on how to treat her redness and burning,” says Dr. Caldwell.

Dr Caldwell also commented adversely on the clinic’s failure to disclose to the woman, its investigation of the event and the cause of the error.

“When the delivery of a health service does not meet expectations, it is understandable that people will ask questions and demand a clear explanation of what went wrong.

“I criticize the clinic for not investigating the cause of the machine error, for not informing the woman of the cause of the event or the outcome of the investigation in a timely manner, and for not apologizing to him in a timely manner,” says Dr. Caldwell.

Following the events of this case, the clinic reviewed its protocols and made several changes to its processes and procedures to reduce the likelihood of a similar error occurring. This included implementing permission checks and restrictions on the UVB computer to ensure no mistakes are made.

After considering the improvements to their service, Dr. Caldwell further recommended that the clinic ensure that those involved issue a written apology to the woman; develop a comprehensive policy for adverse events; provide its reception staff with training in first aid and training in the management of an adverse event; amend the UVB implementation policy to include a more comprehensive double check protocol; and developing an open disclosure policy to ensure patients are kept informed of the status of internal investigations and changes made as a result.

“Internal review of any adverse event is essential to ensure changes are made to prevent a similar event from occurring. I acknowledge that the clinic has taken this issue seriously and commend them for the improvements made. in his service,” says Dr Caldwell.

Editor’s Notes

The full report of this case will be available on HDC’s website. Names have been removed from the report to protect the privacy of those involved in this matter.

The Commissioner will generally name providers and public hospitals that have violated the Code, unless doing so is not in the public interest or unfairly compromises the privacy interests of an individual provider or consumer.

More information for HDC’s media and naming policy can be found on our website here.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Rights for Consumers of Health and Disability Services (the Code).

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