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The following is issued on behalf of the Hospital Authority:
The 33rd issue of "HA Risk Alert" was published today (April 25) by the Hospital Authority (HA) as a risk management and communications initiative to further strengthen the reporting and monitoring of medical incidents in public hospitals.
There were 11 sentinel events reported in the last quarter of 2013, including five cases of retained consumables and instruments, one case of administering the wrong dose of medication and one case of wrong site anaesthetic preparation. The reported events also included four cases of patient suicide. Subsequent to root-cause analysis, recommendations have been made and shared in this publication to avoid similar events happening again in future.
During the reporting period, there were 23 reported serious untoward events, comprising 20 medication incidents and three cases of patient misidentification. Among the medication incidents, the 15 cases of overlooking known drug allergies were highlighted and analysed, alongside recommendations for minimising similar incidents.
The publication shares with colleagues the value of reporting a "near miss" and includes the new feature of the Advance Incident Reporting System which facilitates the reporting of these cases for sharing and learning. The top categories of incidents reported in the Advance Incident Reporting System in 2013 are also included in the latest issue.
The publication has been distributed to all health care professionals in public hospitals for continuous quality improvement purposes. It can also be accessed by the public at www.ha.org.hk/riskalert.
"HA Risk Alert" is published on a quarterly basis and posted on the HA website every last working Friday in the month of January, April, July and October. The next issue will be published on July 25.
Ends/Friday, April 25, 2014
Issued at HKT 16:50
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