Waikato District Health Board says it is updating its records system after a woman had surgery to remove her gall bladder despite having had it removed by the same surgeon 13 years earlier.
The DHB and one of its surgeons have been criticised for the botched operation by Health and Disability Commissioner Anthony Hill in a report released on Monday.
The case involved a 61-year-old woman who underwent the operation in Waikato in June 2009.
Mr Hill says both Waikato District Health Board and the surgeon breached the patient's bill of rights.
The report says the surgeon operated on what he thought was a gall bladder but was in fact a bile duct. As a result, it says, the woman suffered a major duct injury, required reconstructive surgery and had a difficult recovery.
Surgeon failed to notice signs
Mr Hill says the health board failed to supply all information on the patient to the surgeon.
The surgeon in turn failed to notice signs indicating the woman had already had her gall bladder removed.
Waikato DHB says a project is under way to ensure the electronic record is complete and that any incomplete paper records carry warning stickers.
Mr Hill says he has referred the surgeon to the Health and Disability Director of Proceedings, who will decide if disciplinary action is needed.
The surgeon has not been publicly named.