An investigation panel has called for better communication among Queen Elizabeth Hospital staff. The panel investigated the October 2 incident in which a nurse mistakenly rinsed an ultrasound probe in sterilised water set aside for a cystoscope.

The panel concluded today lax communication was the major cause of the incident, apart from flaws in governance, system design and staff communication within the operating theatre leading to individual staff error.

The panel suggested improving task design and source alternative instruments, with a view to standardising sterilisation practice; while occupational safety and health issues, especially in the area of usage of chemical disinfectant, require urgent attention. The governance and staff communication of the operating theatre department should be reinforced.

For patient and staff safety an independent working group should be formed to study and suggest upgrades regarding the use of chemical disinfectant within the cluster.

The hospital has accepted the recommendations and will implement them.