A patient injected with a used needle has been offered an apology from the negligent nurse.
A report by deputy Health and Disability Commissioner Theo Baker published today censured the nurse responsible for sticking two women with the same needle. It recommended the medical centre update its protocol.
On June 27, 2013, two women were booked with the registered nurse to receive a Depo-Provera injection.
Depo-Provera is a hormonal birth control given as an injection into a woman's arm or buttocks every 12 weeks. The nurse had been registered since 1980.
After injecting the first patient, the nurse placed the used needle and syringe back in its box rather than disposing of it. She then used the same needle to inject the second woman.
The report said the nurse realised her mistake immediately, telling the woman the syringe was empty, but not explaining why.
She then allowed the woman to go home without telling her of the error.
The nurse also neglected to check the woman's blood pressure or weight during the appointment, but documented that she had done so. Two of the potential side effects of Depo-Provera are weight changes and increased blood pressure.
The next day, the nurse admitted her error to the practice manager, and was told to tell the woman and the woman's general practitioner.
She failed to do this until after she got back from four days' leave, and then she told only the GP.
The GP immediately contacted the woman and arranged for blood tests for hepatitis B, hepatitis C, and HIV. The blood tests all returned negative.
Baker's findings showed the nurse breached the Code of Health and Disability Services Consumers' Rights for failing to provide services with reasonable care and skill.
The report said the nurse also failed to meet professional standards by not notifying the woman and her GP promptly after the error, and for lying about not checking the woman's blood pressure and weight.
The medical centre had appropriate policies in place relating to administering injections and managing stress in the workplace, Baker said.
However, it needed to be more aware of individual staff stress, and of its ongoing responsibility to ensure all nurses complied with policies, he said.
As a result of the investigation, the nurse attended the Nursing Council of New Zealand's competence assessment, and completed further training.
She resigned from her position at the medical centre on April 17 this year.
The medical centre has hired more staff to relieve pressure on its nurses, reviewed its policies and procedures, and dedicated a clinic room for patients requiring Depro-Provera injections.
The identities of those involved have been suppressed.
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