The Health and Disability Commissioner found a dermatology clinic breached the Code of Health and Disability Services Consumers’ Rights after a man was left badly burnt.
The man was undergoing a course of phototherapy at the clinic to treat eczema. The treatment exposes the skin to
ultraviolet light for a fixed amount of time several times per week.
The man provided his name to an employee when he arrived at the clinic and then confirmed his name a second time as he
wanted to ensure the employee had selected his correct patient profile.
The employee then checked the man’s treatment with the dermatologist, who examined the man’s skin and recommended his
treatment dose be reduced. The man’s treatment protocol was adjusted in the phototherapy system, and the man received
phototherapy treatment for three minutes.
An hour after he left the clinic, the man received a call from the dermatologist advising that he had received the wrong
treatment. The dermatologist said the employee, "had opened a folder for a different patient and loaded their
treatment," which was much stronger than the man’s usual treatment.
The dermatologist apologised and told the man that he would develop bad burns, for which he prescribed aspirin and a
topical steroid cream.
The man’s skin became increasingly red and hot later that day and by the next morning he developed several blisters on
the front of his body. Over the next few days, blistering became worse and covered most of the front of the man’s body,
from his chin to his waist. He had to take two days off work, due to pain that rendered him bed-bound and unable to
carry out daily tasks.
Dr Vanessa Caldwell, Deputy Health and Disability Commissioner, found the clinic breached Right 4 of the Code, for
failing to provide services to the man with reasonable care and skill.
"This complaint highlights how crucial it is for healthcare providers to have suitable processes and measures in place
to identify patients correctly and ensure they receive their own prescribed treatment," Dr Caldwell said.
"It is important that staff are not only trained to follow a process, but also to understand the purpose and order of
steps in that process."
Dr Caldwell said the clinic responded to the incident appropriately by undertaking an investigation and making several
process improvements.
"I commend the clinic’s prompt investigation and its transparency about how the error happened... The changes to the
clinic’s processes were specific and appropriate to reduce the risk of the same error happening again. As human error
was central to what went wrong, it was fitting that additional training was provided to the employee for the same
reason."
Dr Caldwell made several recommendations to the clinic as outlined in the report, including providing confirmation that
the changes indicated have been implemented, and information about the impact of those changes, including confirmation
that no further incidents of this nature have occurred since.
The full report of this case can be viewed on HDC’s website - see HDC's ' Latest Decisions'.