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The following is issued on behalf of the Hospital Authority:
Regarding the investigation on the incident of mixing up specimens of two patients at Tung Wah Hospital (TWH), the hospital spokesperson made the following announcement today (April 30):
Following the incident, an investigation panel was appointed to investigate the incident and to make recommendations on prevention of similar incidents. The members on the panel included Dr Man Chi-wai, Consultant in the Department of Surgery, Tuen Mun Hospital/Immediate Past President of the Hong Kong Urological Association; Dr John Chan, Consultant in the Department of Pathology, Queen Elizabeth Hospita; and Mr Alan Wong, Cluster General Manager (Nursing) of the Hong Kong West Cluster. The investigation report has been submitted to the Hospital Authority Head Office.
The incident related to the mixing up of the prostate biopsy results of two male patients who underwent biopsy in the Geriatric Urology Centre (GUC). The event led to the delayed diagnosis of prostate cancer in one patient and unnecessary radiotherapy for the other.
The panel concluded that the most likely cause of the incident was a change in the scheduled sequence of patients leading to the mixing up of patient identification labels at the time the biopsies were taken in the procedure room of the GUC. Multiple patient records were placed in the procedure room and the label sheets of different patients were clipped according to the original sequence on a clipboard. It appeared that the label sheets of the two patients had been exchanged, resulting in wrong labels put on two sets of specimen bottles for the two patients concerned.
Recommendations of the panel are summarised as follows:
- Improve the procedures on verification of patient identification labels on specimen bottles with the use of advanced barcode technology for laboratory tests.
- Cease the practice of taking out and clipping the identification label sheets of different patients on the same clipboard.
- Enhance clinical supervision and the audit mechanism to ensure compliance of guidelines.
TWH expressed its gratitude to the panel members and accepted the recommendations made in the panel's report. Immediately after the incident, the hospital had already reviewed the relevant operational procedures and a series of improvement measures, such as the proper handling of specimens and labels, had been undertaken or reinforced by the hospital. The health condition of the concerned patients is stable. The hospital explained the investigation result and findings to the patients and their families today as well as the hospital's follow up arrangements. The hospital will continuously provide care to the patients and render the necessary assistance to them. Guidance and counselling will be provided by the management to the staff concerned and the hospital will further review and implement the recommendations made by the panel, in order to strengthen risk management and improve the hospital's standards of patient care and services.
Ends/Wednesday, April 30, 2008
Issued at HKT 20:02
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