Clinic consultation

Dermatologist clinic slammed after burning woman by mixing up patient names

The woman woke up vomiting and struggling to breathe after the phototherapy appointment. Photo: 123RF

A woman suffered extensive burns to her skin after a staff member at a dermatology clinic accidentally typed the wrong name into the system, giving her a significantly higher dose of phototherapy treatment.

The woman was later admitted to the emergency room after waking up vomiting and struggling to breathe, but said she was not given an explanation of what happened until months after the incident and that She had yet to receive an apology from the clinic.

The Dermatology Clinic was today found guilty of violating the Health and Disability Services Consumer Rights Code for failing to provide services with reasonable care and skill.

The woman, identified as Ms B, was receiving treatment for her psoriasis, a skin condition that causes scaly and itchy, dry patches, at a dermatology clinic, which cannot be named.

In March 2020, Mrs B started narrowband UVB treatment, a form of phototherapy used to treat skin conditions, on the advice of her dermatologist, Dr A.

The treatment involved three weekly sessions in which Mrs. B stood in a fluorescent tube machine, with the dose automatically increased in 10-15% increments.

The clinic told the Health and Disability Commissioner that when a patient comes to the clinic for treatment, they check in at reception and give their name. The patient then receives glasses and is invited to go to the treatment room.

In July 2020, Mrs B attended her ninth session on a Friday, as the Covid lockdown delayed her treatment. Her last treatment lasted about two minutes, however, when she entered the machine, an automated voice said the session would last about eight minutes.

Ms B said she was surprised to learn how long the treatment would last but did not question it and stayed in the machine, where she ‘assumed everything would be fine’.

As a result, Mrs. B received 3135 m joules instead of the expected 825 m joules.

Afterwards, she mentioned to the reception staff that the eight-minute session had seemed “strange” to her and said that one of the receptionists looked surprised and replied, “Huh?”

One of the receptionists told HDC that they told Ms B to “report back if there were any issues”.

After Mrs B’s burns, an Incident Assessment Report revealed that the two reception staff working that day were less experienced in managing a busy reception without assistance, as the most experienced was on leave.

Later that day, Ms. B’s skin began to itch and dry around her neck and waist, and her body was flushed all over except her feet and palms.

She contacted the clinic and was told that the practice manager, who was in a meeting at the time of the call, would call her back. However, Mrs B received a call from the receptionist who told her that she could not speak to a doctor as they were all gone for the day.

She was advised to apply aloe vera gel to her skin and was offered an appointment with Dr A on Monday. He was also told to see his GP or an outpatient clinic if his condition worsened.

Throughout the evening, Ms B applied a home remedy of yogurt and egg white to the burn, used sunburn spray and took cool showers to soothe the burn. When her skin deteriorated, her husband took her to an after-hours medical and accident clinic.

There, he was diagnosed with superficial but extensive burns all over his body after the UVB treatment. She received moisturizer, painkiller and a letter of recommendation to go to the public hospital if the pain did not subside.

Ms B went home and fell asleep, but woke up at 3 a.m. vomiting and struggling to breathe. She was rushed to the ER but was discharged with pain relief and Sorbolene cream after a blood test and stomach exam showed normal results.

Ms B told HDC that throughout Saturday and Sunday she was in a lot of pain and discomfort and felt no improvement.

On Monday, Ms B returned to the dermatology clinic to speak with Dr A, who she said was “avoiding” the subject of burns and did not apologize to her, although Dr A told the HDC that he had apologized.

Dr A also said he prescribed prednisone – a steroid drug – to relieve inflammation, and recommended cold baths and Locoid Lipocream10 to be applied to sensitive areas.

Later that day, Mrs B received a text from the clinic stating that the UVB phototherapy device would no longer be available as the staff believed this might be the cause of Mrs B’s burns.

Ms B returned to the clinic on Tuesday after her skin began to peel and turn red and tender on her neck, chest and buttocks.

She told HDC that Dr. A told her she would be better on Thursday and that she was encouraged to take cool showers, but Dr. A said he would never have predicted such a quick recovery at the time. Instead, he agreed to see her every day until she was comfortable.

Two days later Mrs B said she returned to the clinic and asked how the burns had happened and was told the machine had calibration issues.

Dr A told HDC that he informed Ms B of the human error that caused her burns on August 3, as soon as he discovered it himself.

However, Ms B said the first time she was told the wrong name had been typed in was when she read Dr A’s statement to HDC.

On August 28, an Incident Assessment Report was written, shortly after Ms. B filed her complaint with the HDC, which confirmed that the cause of Ms. B’s burns was the wrong name typed in. the system and it was possible that this error could reoccur.

Dr A told HDC that the receptionist could not remember how she typed the wrong name into the system, but was under “considerable pressure” at the time.

Ms B told HDC that at no time did the head of the firm directly apologize to her for these events.

“[Dr A] was slow to apologize, and it wasn’t until I continued to mention the fact that I hadn’t been contacted or offered an explanation, that he gave me a quick apology and then did move the conversation on…I continue to expect a direct apology.”

The clinic told HDC that while it recognizes that a mistake was made by a staff member less experienced than its senior receptionist, it would not classify the staff member as inexperienced.

The clinic also said the machine is now behind schedule due to Covid-19 related delays and has not worked.

Dr A said they wanted to ‘reiterate the clinic’s apologies’ to Ms B ‘for the shortcomings in the care she received’.

“We accept that these shortcomings resulted in [Mrs B] suffers from superficial burns and also acknowledges the distress these events have caused him. »

The Assistant Commissioner for Health and Disability, Dr Vanessa Caldwell, concluded that the clinic’s failure to adequately supervise and train staff led to the initial error, as well as their inappropriate actions by thereafter, and therefore found them to be in violation of the Code.

“I consider that the clinic staff were not sufficiently supported or trained in their role to provide safe care. As a result, the woman received the dose from another patient and did not receive any medical advice on how to deal with the resulting redness and burning.”

Caldwell also criticized the clinic for not investigating the cause of the machine error, not informing the woman of the cause of the error, and not apologizing to her in a timely manner.

After considering improvements to their service, Caldwell further recommended that the clinic ensure that those involved issue a written apology to the woman and improve policies around staff training and setting up the UVB.