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 healthcare services was highlighted in a decision published by Deputy Health and Disability Commissioner Dr Vanessa Caldwell.

In her decision, Dr Caldwell found a dermatology clinic in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide services with reasonable care and skill.

A woman was receiving narrowband UVB treatment (a form of phototherapy used to treat skin diseases), for her psoriasis from a dermatologist at a dermatology clinic. She had attended eight sessions with a slowly increasing dosage with no adverse reactions. On her ninth session, staff mistakenly entered the incorrect name into the system, and the woman received a longer session than expected. This led to the woman receiving a significantly higher dose of narrowband UVB, resulting in burns across her body. On advising the clinic of these burns she was not given advice regarding treatment and instead was advised that a doctor would be available in a couple of days. The woman later presented to the Emergency Department and was treated for pain and burns. The clinic failed to inform the woman about its investigation into the error, and did not tell her about the cause of the error.

Dr Caldwell concluded the clinic’s failure to supervise and train staff adequately led to the initial error, as well as their inappropriate actions afterwards, and therefore found them in breach of the Code

"Staff need adequate support and training to enable them to provide appropriate advice to patients in the case of an adverse event, and to have in place a clear line of escalation so patients can receive appropriate follow-up care.

"I consider staff at the clinic were not supported or trained in their role adequately to provide safe care. As a result, the woman was given another patient’s dose, and was not provided with medical advice on how to treat her resulting redness and burns," says Dr Caldwell.

Dr Caldwell also made adverse comment about the clinic’s failure to disclose to the woman, its investigation into the event and the cause of the error.

"When provision of a health service is not as expected, it is understandable for people to have questions and to seek a clear explanation of what went wrong.

"I am critical of the clinic for failing to investigate the cause of the machine error, for not informing the woman of either the cause of the event, or the outcome of the investigation in a timely manner, and for failing to apologise to her in a timely manner," says Dr Caldwell.

Following the events of this case, the clinic reviewed its protocols and made multiple changes to its processes and procedures to reduce the likelihood of a similar error occurring. This included implementing checks and restricted permissions on the UVB computer to ensure errors are not made.

After taking into account the improvements made to their service, Dr Caldwell further recommended the clinic ensure the individuals involved provide a written apology to the woman; develop a comprehensive policy for adverse events; provide its reception staff with first aid training, and training on managing an adverse event; amend the UVB set-up policy to include a more comprehensive double-checking protocol; and develop an open disclosure policy to ensure that patients are kept up to date with the status of internal investigations and the changes made as a result.

"Internal review of any adverse event is vital to ensure changes are made to prevent a similar event from occurring. I acknowledge the clinic has taken this issue seriously and commend them on the improvements made to their service," says Dr Caldwell.

Editors notes

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

The Commissioner will usually name providers and public hospitals found in breach of the Code, unless it would not be in the public interest, or would unfairly compromise the privacy interests of an individual provider or a consumer.

More information for the media and HDC’s 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 Health and Disability Services Consumers' Rights (the Code).

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