A man developed burns and blisters across the front of his body after he was given the wrong treatment for his eczema.
The Health and Disability Commissioner released a report today finding the clinic he went to in breach of its code after the man was left badly burnt.
The man was having his eczema treated at the clinic by using phototherapy, which uses ultraviolet light to treat the skin. The strength of the light used is prescribed by a doctor, typically a dermatologist.
The man arrived for his appointment on November 4, 2022, and provided his name to the employee twice before a dermatologist examined his skin and recommended his treatment dose be reduced.
The man's treatment protocol was adjusted in the phototherapy system, and the man received phototherapy treatment for three minutes.
However, an hour after he left the clinic, he got a call from the dermatologist telling him he had received the wrong treatment.
The dermatologist said the employee, "had opened a folder for a different patient and loaded their treatment," which was much stronger than the man's usual treatment, the report said.
The dermatologist apologised and told the man that he would develop bad burns, for which he prescribed aspirin and a topical steroid cream.
The man told the Commissioner his skin became increasingly red and hot, and by the next morning, he had developed several blisters on the front of his body.
The blisters became worse over the next few days, covering his chin to his waist.
The man said he had to take time off work because the "severe" burns and blisters caused him "considerable pain, discomfort, and stress and left him unable to sleep and bed-bound for four days overall", the report said.
"He said that while the blisters started to dry out on Monday, the skin around his torso started to crack and peel badly, leaving behind 'raw' skin, and he had to work from home for the rest of the week as it was difficult for him to put on, and wear, a shirt," the report said.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the clinic, which has not been named, in breach of the Code for failing to provide services to the man with reasonable care and skill.
"This complaint highlights how crucial it is for healthcare providers to have suitable processes and measures in place to identify patients correctly and ensure they receive their own prescribed treatment," Dr Caldwell said.
"It is important that staff are not only trained to follow a process but also to understand the purpose and order of steps in that process."
The clinic launched its own investigation and the clinic's practices and policies were updated to mitigate the risk of recurrence in future.
The dermatologist told the Commissioner it was a "deeply unfortunate error" and he was sincerely sorry that it resulted in the man suffering burns.
"I commend the clinic's prompt investigation and its transparency about how the error happened... The changes to the clinic's processes were specific and appropriate to reduce the risk of the same error happening again. As human error was central to what went wrong, it was fitting that additional training was provided to the employee for the same reason."
Dr Caldwell made several recommendations to the clinic, including providing confirmation that the changes indicated have been implemented, and information about the impact of those changes, including confirmation that no further incidents of this nature have occurred since.
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