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The following is issued on behalf of the Hospital Authority:
In response to media enquiries, a Tuen Mun Hospital (TMH) spokesman gave the following reply today (March 10):
A healthcare staff of a Medical and Geriatric Ward mixed up the labels of the blood samples of two female patients (aged 70 and 85) in the early morning of November 11, 2007. As a result, one patient received unnecessary oral intake of potassium.
The hospital discovered the incident in the morning of November 11 while examining one of the two patients as the test result conflicted with the clinical presentation. The hospital immediately examined the two patients again and provided appropriate treatment. The families of the two patients were informed immediately while a detailed explanation was given by the clinicians in a meeting the following day. The two patients were discharged on November 16 and 19 respectively.
The incident has been reported to the hospital management and Hospital Authority Head Office (HAHO) through the "Advanced Incident Reporting System". The incident has been considered according to its seriousness, the impact and the patient condition. It was subsequently decided to capture it in the "Medication Incident Reporting Programme", which will be followed up in accordance with usual practice.
After the incident, the hospital management met with the concerned staff members to investigate the incident and review the checking procedures related to patient identification and test samples labelling. Staff members have been reminded to be vigilant to avoid a recurrence of similar incident. Pamphlets have been produced to remind healthcare staff to "print labels before blood taking" during the blood taking process. An educational video has also been produced on blood taking and matching. In view of the heavier workload, TMH has trained more phlebotomists to share the workload of healthcare staff.
The Hospital Authority (HA) spokesman confirmed receiving a report through the Advanced Incident Reporting System from Tuen Mun Hospital in November last year regarding a blood sample labelling mix-up incident. After reviewing the incident, HA considered that the incident did not belong to one of the nine types of Sentinel Events. It was subsequently captured in the Medication Incident Reporting Programme as it involved drug administration.
The nine types of Sentinel Events are as follows:
1. Surgery/interventional procedure involving the wrong patient or body part.
2. Retained instruments or other material after surgery/interventional procedure requiring re-operation or further surgical procedure.
3. Haemolytic blood transfusion reaction resulting from ABO incompatibility.
4. Medication error resulting in major permanent loss of function or death of a patient.
5. Intravascular gas embolism resulting in death or neurological damage.
6. Death of an in-patient from suicide (including home leave).
7. Maternal death or serious morbidity associated with labour or delivery.
8. Infant discharged to wrong family or infant abduction.
9. Unexpected death or serious disability reasonably believed to be preventable (not related to the natural course of the individual’s illness or underlying condition). Assessment should be based on clinical judgment, circumstances and context of the incident.
To further enhance safety of blood handling, HA has also allocated resources on the implementation of an electronic barcode system (unique patient identification) for all blood testing to minimise the occurrence of similar events. The system will be first implemented in several pilot centres (including Tuen Mun Hospital) this year.
Ends/Monday, March 10, 2008
Issued at HKT 18:26
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