The Ministry has received the external review and we welcome the recommendations that have been put forward.
"Echoing what the reviewers have said, we support the approach taken by the DHB and acknowledge the DHBs handling of the event," says Dr Andrew Simpson, Chief Medical Officer, Ministry of Health.
"I know how important it is for the DHB to keep patients and the wider public regularly informed about progress with the investigation and supported in a timely and professional way."
"The safety and health of every patient is paramount."
The external review has highlighted changes for the DHB to implement and changes for the Ministry to note in order to prevent further incidents occurring.
The review has made the following recommendations for all DHBs.
- Electronic tracking and traceability systems should be installed in all sterile service units and operating theatres
- Tracking should be extended out to include all reusable medical devices used in wards and outpatient clinics
- Annual auditing of CSSD/SSU departments against the standard AS/NZS4187:2014.
The Ministry will now work with DHBs to ensure these recommendations are acted on.
"As Chief Medical Officer, I am planning a teleconference after Easter with colleagues from DHBs around the country to discuss the recommendations and agree on next steps," says Dr Simpson.
"Ultimately the safety and health of every patient is paramount to us and to every DHB. I’m confident these changes will help to prevent such an event occurring in the future."