Ruttonjee and Tang Shiu Kin Hospitals announce incident of using expired diathermy pens
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The spokesperson for Ruttonjee and Tang Shiu Kin Hospitals made the following announcement today (April 3) regarding an incident of using a batch of expired diathermy pens on patients during surgical procedures:
On April 1, 2017 (Saturday), a report on the storage of a batch of 39 expired diathermy pens in operating theatres at Ruttonjee Hospital was made during a routine checking of items. A diathermy pen is a device used in surgery either as a cutting modality or to cauterise small blood vessels to stop bleeding. The concerned batch of diathermy pens with an expiry date in February 2017 was used on patients who had undergone surgery (including polypectomy, cholecystectomy, thyroidectomy, adrenalectomy, mesh repair and skin grafts) from March 27 to 31. The individual vacuum-sealed package of each diathermy pen was sterilised and found intact.
The hospital management is highly concerned about the incident after receiving the report. Immediate actions were taken to consult the opinions of surgical and infection control experts regarding the risk of using expired diathermy pens, while at the same time starting to trace and ascertain the number of patients involved. According to the experts, it was improper to use disposable diathermy pens beyond the expiry date. However, they said the infection risk of using an expired diathermy pen with heat generated in the process is very low.
Initial investigation found that 11 patients (six males and five females, aged 32 to 95) are involved, and there was no report of abnormality in post-operation infection for use of expired diathermy pens. Among the 11 patients, eight have been discharged and the remaining three are still hospitalised and in a stable condition. The hospital has started to contact all patients concerned to explain the situation and to extend its apologies. Patients' conditions will be closely monitored and appropriate tests will be arranged if necessary to ensure patient safety.
The incident has been reported to the hospital management and Hospital Authority Head Office (HAHO) via the Advance Incident Reporting System. A thorough investigation with an aim of preventing the recurrence of similar incidents will be conducted. The investigation will be completed in six to eight weeks and the report will be submitted to the HAHO.
In operating theatres, a system is in place to ensure safety in the use of medical equipment and products. After the incident, a stock-taking exercise in the operating theatres was conducted to further ensure the quality and safety of medical equipment and products. The hospital has also reminded its staff to stay alert on safety issue of medical supplies.
Ends/Monday, April 3, 2017
Issued at HKT 19:45
Issued at HKT 19:45
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