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The following is issued on behalf of the Hospital Authority:
The Hospital Authority (HA) spokesman today (November 12) announced the following incident concerning the electronic radiology reports of two cancer patients who were referred to Tsuen Wan Adventist Hospital (TWAH) to undergo Computed Tomography (CT) scan:
The HA Head Office was notified by Princess Margaret Hospital (PMH) on November 5 that a nursing staff, when reviewing a colorectal cancer patient's electronic record on November 4, noted that the CT report received from TWAH belonged to another patient. The cancer patient was earlier referred to TWAH to undergo CT scan on October 30 under HA's "Pilot Project on Enhancing Radiological Investigation Services through Collaboration with the Private Sector" (Radi Collaboration Pilot Project).
Upon identifying the case, PMH immediately notified TWAH and a replacement CT report was transmitted to PMH through the electronic patient record platform on the same day. As the next clinic appointment for the patient was scheduled on November 6, which was after the replacement report was provided, there was no clinical impact on the patient. The patient was fully informed and explained on the incident.
While investigating the incident at PMH, TWAH notified HA on November 7 of another case of mis-identified CT report concerning a colorectal cancer patient of Tuen Mun Hospital (TMH) who underwent CT scan at TWAH on October 30. TMH was informed immediately and a replacement CT report was provided.
According to TMH, the patient concerned was followed up on November 4 before the replacement CT report was provided. On review of this case, no significant clinical impact on the patient was noted and the patient will continue treatment and follow up at TMH. TMH will proceed with his cancer treatment as initially planned. In addition, urology consultation will also be arranged alongside the incidental finding as reflected in his CT report. TMH has explained the incident and sent apologies to the patient.
The initial finding of TWAH revealed that the incidents were likely due to the loading test of a new Radiological Information System in TWAH commencing October 16. TWAH, with the assistance of HA, reviewed all relevant CT reports from October 1 and no other case of mis-identified CT report was found.
Immediate measures have been taken by TWAH to stop the loading test and to carry out both system and manual checks to strengthen the patient identity verification process for all cases under the Radi Collaboration Pilot Project. In the long run, TWAH has committed to putting in place an advanced version of IT system to ensure verification and accuracy of patient records.
HA is very concerned about the two incidents and has requested TWAH to thoroughly investigate and submit a full report. HA will continue to closely monitor the performance of TWAH and the implementation of the enhanced measures, and will share with and remind other service providers under the Radi Collaboration Pilot Project to ensure accuracy of patient identification.
The two incidents have been reported to the Department of Health by TWAH.
The HA Radi Collaboration Pilot Project was launched in May last year which is a government-funded project aiming at enhancing radiological investigation services for four groups of cancer patients (viz colorectal cancer, breast cancer, nasopharyngeal cancer and lymphoma) through collaboration with the private sector. Apart from TWAH, other private collaborators in the project are St. Paul's Hospital, Hong Kong Health Check, iRad Medical Diagnostic Centre and Union Hospital.
Ends/Tuesday, November 12, 2013
Issued at HKT 20:54
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