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The following is issued on behalf of the Hospital Authority:
The latest quarterly issue of "HA Risk Alert" was published today (January 23) by the Hospital Authority (HA) as a risk management and communication initiative to further strengthen the incident reporting and sharing of lessons learnt for safety improvements in public hospitals.
The current issue of "HA Risk Alert" reports one case of wrong side procedure, three cases of retained instruments and one case of patient suicide. Among the reported serious untoward events, there were 24 medication incidents and two cases of patient misidentification. Subsequent to incident review and analysis of root causes of these incidents, important lessons of patient safety are identified, while recommendations are made and shared in this publication to avoid similar events in future.
Furthermore, the HA also released the Annual Report on Sentinel and Serious Untoward Events covering the 12 months from October 1, 2012, to September 30, 2013, which was discussed and endorsed by the HA Board today.
For this year's report, there were a total of 26 sentinel events reported during the period, as compared with 34 cases in last year's report. The decrease was recorded for the second year running.
Serious untoward events are unexpected occurrences which did not cause death or permanent harm to patients but would have had the potential to do so without timely intervention. During the year, 104 serious untoward events were reported, with 96 and eight events related to medication error and patient misidentification respectively.
The Annual Report on Sentinel and Serious Untoward Events can be accessed by health-care workers and the public at www.ha.org.hk/report/sentinel_event, while "HA Risk Alert" has been distributed to the health-care professionals in public hospitals for continuous quality improvement purposes and can be accessed by the public at www.ha.org.hk/riskalert. The next issue will be published on April 25.
Ends/Thursday, January 23, 2014
Issued at HKT 18:20
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