According to an internal inspection, undertaken by HSE auditors, on emergency, elective and day procedures at Tipperary University Hospital (TUH); a listing used to ensure HSE safe surgery is being followed, was not located in healthcare records. The failure was discovered following a random sample, taken of 15 patients, latter who had undergone surgical procedures at TUH, Clonmel, Co Tipperary, just last year.
The HSE audit report revealed that it could only provide limited assurance regarding the adequacy and effective governance relating to risk management and the internal control system, at the hospital, when it came to HSE strict policy on safe surgery.
HSE auditors had carried out a retrospective random sample on healthcare records of 15 patients out of a total of 96. Same had undergone surgery or an endoscopy at TUH, over a seven-day period in July 2024. Same audit was undertaken to check that planned surgery was clearly documented and that consent was obtained and recorded for each surgical procedure.
While, TUH had amalgamated aspects of the required checklist into its care plans, latter recommended in the HSE’s National Policy and Procedure for Safe Surgery; the audit found that the HSE’s actual checklist was not found in any medical records reviewed, in relation to the auditors random sample of 15 procedures which had been carried out on site within the hospital.
The report stated that there was a risk that variances between the hospital’s care plans and the official checklist “may result in sub-optimal implementation” of the HSE’s policy on safe surgery “with potential adverse consequences for patients.“
Among questions on the checklist which were not included in the HSE’s recommended care plan were:
(A) If the procedure had been confirmed with a parent or guardian in the case of children and if prophylactic antibiotics were required.
(B) Failure to check if a healthcare record number matched the number on the patient’s wristband or if protocols were in place if the patient suffered unexpected blood loss.
(C) TUH included some questions that were completed after an anaesthetic was administered, which should have been carried out beforehand under the rules as set out in the HSE checklist.
(D)TUH was unable to provide records about the number of medical staff who had completed a mandatory course on safe surgery.
The audit further concluded that recommended pre-surgery briefings among medical staff at TUH Clonmel, resembled “nursing huddles” as opposed to multidisciplinary briefings, of which not all members of the theatre team were found to be present at such meetings. The report also noted that non-attendance of key members could result in critical information not being properly transferred, thus resulting in potential harm to patients.
The HSE auditors issued a total of four recommendations, including that all components of the HSE’s checklist for safe surgery be incorporated into the relevant care plans at TUH, or, alternatively that the checklist be adopted as a standalone document by the hospital.
TUH management have now agreed to the implementation of all the recommendations conveyed by the HSE audit.
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