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The following is issued on behalf of the Hospital Authority:
Queen Elizabeth Hospital (QEH) today (December 4) submitted the investigation report on the incident concerning sterilisation procedures which occurred at QEH to the Hospital Authority head office. The hospital spokesperson made the following announcement today :
An investigation panel was appointed immediately following the incident to investigate the root cause of the incident and to propose improvement strategies in chemical sterilisation. The panel was composed of the Deputy Hospital Chief Executive of QEH, the Consultant Microbiologist of QEH, the Department Operation Manager (Operating Theatre) of United Christian Hospital, the Nursing Officer (Operating Theatre) of QEH, and a Risk Management Manager.
The background of the incident was related to the plan of QEH's Operating Theatre (OT) to replace the usage of disinfectant Cidex with Cidex OPA, mainly for occupational safety and health reasons. However, in view of the fact that the new disinfectant, Cidex OPA, could not be used for patients with or suspected to have bladder cancer due to possible anaphylactic reactions, the old Cidex would continue to be used for sterilisation of urological instruments.
An alternative plan was drawn up specifically for disinfection of urological instruments, whereby the Cidex disinfection was carried out in the Central Preparation Room (CPR) of the Operating Theatre.
The incident happened when two trays (both marked Cidex) were placed side by side in the CPR without clear labels, one containing Cidex solution and the other, sterile water (for initial rinsing of urological instruments after Cidex disinfection). A nurse, who had mistaken the tray of sterile water as Cidex OPA, immersed a clean but non-sterilised ultrasound probe in the tray of sterile water, resulting in the contamination of the sterile water. Other nurses subsequently immersed the urological instruments in the tray of contaminated sterile water.
The panel concluded that the lack of effective communication within the department was the major cause of the incident apart from the flaws in governance, system design and staff communication within the OT leading to individual staff error. Guidance and counselling were provided to the staff concerned.
The panel also recommended that the hospital improve task design and source alternative instruments, with a view to standardising sterilisation practice, while occupational safety and health issues, especially in the area of usage of chemical disinfectants, require urgent attention. The governance and staff communication of the OT department should be reinforced. Furthermore, an independent working group should be formed to study and suggest improvement measures regarding the use of chemical disinfectants within the Cluster for patient and staff safety.
QEH accepted the recommendations made in the panel's report and will implement the improvement measures. Immediately after the incident, the hospital had already revisited the disinfection and sterilisation policy and risk assessment on related procedures was conducted. Other measures including strengthening staff supervision and fostering staff's alertness on related guidelines were implemented. With Cluster senior management support, good governance in the OT and effective staff communication, the chance of recurrence of similar incidents will be minimised in future.
Ends/Tuesday, December 4, 2007
Issued at HKT 19:41
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