A dermatology clinic has been found in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) after a woman was left with burns across her body after receiving UVB treatment.
The woman was receiving narrowband UVB treatment (a form of phototherapy used to treat skin diseases) for psoriasis.
She went to eight sessions with a slowly increasing dosage and had no adverse reactions to the treatment.
However on the ninth session, staff entered the wrong name into the system giving the woman a longer session than she was meant to have.
The woman then told the clinic about the burns but wasn't given any advice and was told a doctor would be available to see her in a couple of days.
She later went to the Emergency Department where she was treated for pain and burns. The clinic also failed to tell the woman about its investigation into the error.
Caldwell said the clinic’s failure to supervise and train staff properly is what led to the incident and therefore found them in breach of the Code
"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," she said.
She said after the incident, the clinic reviewed its protocols and made changes to its processes to reduce the likelihood of a similar error.
Caldwell said she also made a raft of recommendation to the clinic including providing a written apology to the woman.
"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," she said.
SHARE ME