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The following is issued on behalf of the Hospital Authority:
The Hospital Authority (HA) Board discussed and endorsed at its Administrative and Operational Meeting today (January 22) the first Annual Report on Sentinel Events covering the 12 months from October 1, 2007, to September 30, 2008.
Members noted that the HA Sentinel Event Policy was introduced in October 2007 to further strengthen the reporting, management and monitoring of serious medical incidents in public hospitals. The first half year report was issued in July 2008, which covered all incidents that were reported from October 1, 2007, to March 31, 2008. HA Chief Executive Mr Shane Solomon said that the policy has enabled the HA to learn from the reported events to improve the system and processes to enhance patient safety.
During the 12-month period ending September 30, 2008, a total of 44 sentinel events were reported, with 23 cases in the first half year of the policy implementation and 21 in the latter half. The top three categories of reported sentinel event were:
- 25 cases of death from in-patient suicide or during home leave
- 10 cases of retained instruments or other material after surgery / interventional procedure requiring re-operation or further surgical procedures
- five cases of surgery / interventional procedure involving the wrong patient or body part
"Important lessons learned from the root causes analysis of the events were shared amongst all HA staff in the bi-monthly 'HA Risk Alert'," Mr Solomon added.
He also highlighted to members several key improvement measures in system enhancement and work process reviews, "for instance, 2D barcode technology has been used as an adjunct for positive patient identification and a 'time-out policy' is being considered to prevent wrong surgery/ intervention performed on wrong patients or at wrong sites."
The Annual Report on Sentinel Events can be accessed by health care workers and the public at www.ha.org.hk/report/sentinel_event.
Ends/Thursday, January 22, 2009
Issued at HKT 19:10
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