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Doctor promises practices will never occur again
Mac Olsen
for South Peace News
A “culture of conformity” existed in the operating rooms at the High Prairie Health Complex regarding single-use syringes for multiple patients.
It is one of the conclusions of the Health Quality Council of Alberta’s report into single-use syringes for surgeries and endoscopy procedures in multiple patients at the hospital between 1990-2008.
The report is based upon interviews with medical staff, as well as reviews of documentation.
Dr. Robin Laughlin, chief of staff, offers an explanation for his lack of awareness and the actions of the nursing staff.
“Unfortunately, I didn’t know it was happening, although I was doing endoscopies,” says Laughlin. “We initially started by me telling the nurses what dose to use and over the many years of doing (endoscopies), they got more and more comfortable at deciding doses themselves. They would only ask me if there was an issue, so I just let them go ahead and give the medication.”
However, it was only after the event they discovered what was happening and he had no idea how long it had been occurring.
“I realized that this was something that the nurses had picked up from one of our anesthetists. If I had known this, I certainly wouldn’t have been in favour of it.”
Laughlin also says the report is right about two things; there was “isolation” and a “hierarchical problem.”
But such occurrences will never happen again and the practice is widespread, not just in Alberta, he adds.
Finger pointing and laying blame are not the intentions of the council’s report, says co-author Dr. John Cowell.
“It’s merely a warning that you’ve got to be careful that you don’t become comfortable in your historical practices,” says Cowell.
“The point should be made that the local people were very co-operative, very open and I’m personally convinced that none of them thought they were doing anything wrong at all.”
The council started their investigation in January 2009 and released their final report July 21. The team included experts from outside Alberta, who conducted intense interviews and documentation reviews.
He adds the review team came to the conclusion the operating room staff tended to conform to each other’s practice, as opposed to being fully aware of what the newer standard of care was in the re-use of single-use syringes.
“This is not uncommon, that operating room staff become very similar in their practices and don’t tend to challenge each other. We’re saying you’ve got to do that from time to time as you become aware of external standards. Then you’ve got to stand back and say, ‘Wait a minute. Is there a new way, a better way, of doing things?’”
The report has been submitted to the hospital administration and professional group, Health and Wellness Minister Ron Liepert, Alberta Health Services, the physician and nursing associations and regulatory bodies.
Patients were not interviewed for the report, as it was an internal review for the way in which the technical and administrative staff was using a device. The syringe was not used directly on their bodies through a needle, but attached to tubing, he adds.
However, 1,378 patients were identified for testing, although 58 people could not be located.
“The vast majority of these patients, more than 1,100 people, received testing and to date there has been no evidence of any transmission of disease to patients from this incident,” says Dr. Albert de Villiers, the medical officer of health for the north zone, in a news release.
Testing will be offered to those not located, should they come forward.
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