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The following is issued on behalf of the Hospital Authority:
The 34th issue of "HA Risk Alert" was published today (July 25) by the Hospital Authority (HA) as a risk management and communication initiative to further strengthen the reporting and monitoring of medical incidents in public hospitals.
There were 14 sentinel events reported in the first quarter of 2014, including seven cases of retained consumables and instruments, a case of administering unintended continuous prescription and a case of wrong side procedure. The reported events also included four cases of patient suicide and a case of maternal death. Subsequent to root cause analysis, recommendations have been made and shared in this publication to avoid similar events happening in the future.
During the reporting period, there were 31 reported serious untoward events, comprising 29 medication incidents and two cases of patient misidentification. Among the medication incidents, the 17 cases of overlooking known drug allergy were analysed by their frequency of occurrence in various drug types.
The publication shared with colleagues a few near-miss events related to Magnetic Resonance Imaging safety. Colleagues are reminded of some common non-MRI compatible devices, the risks of which range from causing device failure to patient's burning or death.
The publication has been distributed to all health-care professionals in public hospitals for continuous quality improvement. 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 is scheduled to publish on October 31.
Ends/Friday, July 25, 2014
Issued at HKT 16:45
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