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The following is issued on behalf of the Hospital Authority:
The United Christian Hospital (UCH) today (12 December) submitted the investigation report on the incident of mislabelling of blood specimen to the Hospital Authority Head Office. The UCH spokesperson made the following announcement:
Following the incident, an investigation panel was appointed immediately to investigate the root cause of the incident and to make recommendations for improvements. The panel membership comprised a member of the hospital governing committee of UCH, the Chief of Service (Pathology) of Queen Elizabeth Hospital, the Advanced Practise Nurse (Operation Theatre) of UCH, the Senior Medial Technologist (Pathology) of UCH, a risk management director and an administrative manager of UCH.
The incident happened when the blood specimens of two patients arrived at the laboratory of UCH on October 14, 2007, morning. The computer system of the Pathology Department, the Generic Clinical Request System, was under routine checking and maintenance at that time.
According to established protocols and guidelines, certain procedures have to be handled manually during system maintenance. Two laboratory staff were then on duty. One of the laboratory staff had cross-labelled the specimens and request forms of the two patients concerned, indirectly leading to the unnecessary blood transfusion for one patient while causing delay in the transfusion for another patient.
The incident was noticed by the laboratory staff on October 15, 2007, when examinations were being carried out for the two concerned patients, and discrepancies were identified in their blood tests when compared with previous results. The hospital immediately arranged examination and provided appropriate treatment to the two patients once the incident was reported. It was confirmed that there was no adverse clinical effect on the patients. UCH will continue to follow up and monitor the clinical condition of the two patients. The two patients were discharged on October 17 and 18 respectively.
The panel concluded that the incident involved both human and system factors, and made the following recommendations for improvements:
Human Factor – Communication/Training
1. Provide refresher training for hospital staff who will be on duty during computer downtime
2. Conduct audits to ensure compliance of standard operation procedures
System Factor – Policies/Environment/Equipment
1. Use pre-printed labels with patients' name and identity card number as two unique patient identifiers for specimen labelling, instead of using the number tag of the request form as a label
2. Reinforce to the laboratory staff that they should handle one specimen at a time
3. Implement auto-numbering to minimise manual handling when the computer system is in use
4. Enforce "one request form and its related specimen(s), one bag" policy in transportation. Ensure all specimens and forms were individually placed in bags
5. Improve manpower to handle manual registration during computer system downtime
6. Review relevant standard operation procedures to reduce system errors including manual registration, downtime procedures and handling of data checking
7. Consider a back-up system during computer downtime
UCH has accepted the recommendations made in the panel's report and will implement the improvement measures. Following the incident, monitoring of the relevant operational procedures and staff awareness has been immediately enhanced to prevent recurrence of similar incidents. In accordance with human resources policy, a verbal warning was issued to the member of staff and recorded in that staff member's personnel file.
Ends/Wednesday, December 12, 2007
Issued at HKT 19:27
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