Rotorua Hospital staff have been told to contact the region's Medical Officer of Health with any Ebola-related concerns after a man who returned from working in Ebola-hit Sierra Leone was put in a hospital room with other patients.
A report after the incident said the man, who had been working in an administrative capacity with the international response to Ebola, went to Rotorua Hospital earlier this month with a knee injury.
He had returned from Sierra Leone 16 days earlier, where he had had no contact with Ebola patients.
He was treated at the Rotorua Hospital emergency department and discharged after being assessed for Ebola symptoms, but did not show any.
Later that day he had returned with different symptoms, unrelated to the injury. On that occasion there was no documentation in the emergency department or general surgical registrar admission notes regarding the man's travel history and no further assessment on Ebola. He was admitted and put in a four-bed surgical unit room along with other patients.
It wasn't until hours later that admission notes written by the house officer had indicated an assessment had occurred and later a nursing staff member reading the notes became concerned the man was alongside other patients.
The Medical Officer of Health was then alerted, as was the National Ebola Technical Advisory group, which did a full assessment of the patient and found no Ebola symptoms.
Key findings of the review included the person should have been in a side room as a precaution.
It recommended staff be aware of the need for "clear and complete documentation and even clearer communication" with any patient who presented with a travel history that might raise the suspicion of Ebola or any other highly infectious illness.
It also said the Medical Officer of Health had to be consulted with any Ebola-related concerns.
Lakes District Health Board chief executive Ron Dunham said the incident provided a good test of systems. It indicated the need for staff to listen more to the travel history of a patient and not just reply on symptoms a patient arrived with.
He said the report outlined that the patient at no stage showed any symptoms that were remotely linked to Ebola and the only link was his travel history. It was now a matter of taking from the learnings and enacting the recommendations.