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The following is issued on behalf of the Hospital Authority:
The 19th issue of "HA Risk Alert" was published today (November 26) by the Hospital Authority (HA) as a risk management and communication initiative to further strengthen the reporting and monitoring of adverse incidents in public hospitals.
In this latest issue, the HA's newly appointed Chief Executive Dr Leung Pak-yin said he was pleased to see colleagues showing great courage through their willingness to share, discuss, and address the root causes identified by the investigation of adverse incidents.
"The success of patient safety programmes depends on staff commitment to learn and work together. I hope we can nurture greater awareness of what can go wrong and greater willingness to reduce potential risks and hazards," he said.
Among others, this issue includes articles on a patient suffering from an acute stroke after removal of jugular catheter, and a case of wrong-sided pleural paracentesis. Subsequent in-depth root-cause analyses of incident investigation and recommendations are made and shared in this publication to avoid similar events in future.
A number of Serious Untoward Events involving medication errors of vasopressors and inotropes were featured to heighten staff awareness on wrong drugs, wrong dosage, and wrong administration route.
The top reported incidents of Advance Incident Reporting System in the first two quarters of 2010 are also charted in this issue.
The publication has been distributed to all health care professionals in public hospitals for continuous quality improvement purposes. It can also be accessed by the public at www.ha.org.hk/riskalert.
"HA Risk Alert" is regularly published and posted on the HA website every last working Friday in alternate (odd) months. The next issue will be published on January 28, 2011.
Ends/Friday, November 26, 2010
Issued at HKT 17:45
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