**************************
Following is a question by the Hon Emily Lau and a written reply by the Secretary for Food and Health, Dr York Chow, in the Legislative Council today (June 18):
Question:
It has been reported that the New Territories East Cluster (NTEC) of the Hospital Authority (HA) has implemented the revised "3 Checks and 5 Rights" procedures since April 2006 with a view to reducing errors in dispensing drugs. Yet, a medication incident in which health care practitioners dispensed the wrong drugs to an elderly patient for seven consecutive days still occurred in the Shatin Hospital under NTEC last month. In this connection, will the Government inform this Council whether it knows:
(a) if HA has conducted a thorough investigation into the aforesaid incident; if it has, of the investigation results; if not, the reasons for that;
(b) the number of medication incidents that have occurred in the public hospitals under NTEC since the implementation of the revised "3 Checks and 5 Rights" procedures, and how the figure compares to those of the two years before implementation;
(c) as the Chief Executive of NTEC said in September last year that upon the implementation of the "3 Checks and 5 Rights" procedures, there might still be loopholes in the dispensation procedures that could lead to the dispensation of wrong drugs, with the main loopholes being health care practitioners misidentifying drugs or patients, insufficient communication among staff during shift handovers and illegible handwriting on doctors' prescriptions, what measures HA has put in place to plug these loopholes;
(d) as some experts have pointed out that the increasing numbers of items of check-ups and laboratory tests on patients in recent years have made it more difficult for health care practitioners to cross-check information, whether HA has assessed if there are currently enough frontline staff to perform the "3 Checks and 5 Rights" procedures; if there are enough staff, of the details; if not, the reasons for that; and
(e) as HA advised in September last year that it was studying the introduction of an electronic procedure for dispensing drugs in hospital wards, of the latest progress of such a plan?
Reply:
Madam President,
(a) The incident took place on May 14, this year when a nurse of the Prince of Wales Hospital (PWH) mistakenly filed a prescription record of Patient A in the medical record of Patient B, who was subsequently transferred to the Shatin Hospital (SH) together with the medical record on the same day. After a doctor of SH attended Patient B, the doctor wrote a prescription to Patient B by reference to Patient B's treatment record at PWH. Being unaware of the fact that Patient A's prescription record was mistakenly filed in Patient B's medical record, the doctor was misled to prescribe to Patient B a drug (Lisinopril, which is a light dosage of an anti-hypertensive drug) that Patient B did not need to take. Later, when the doctor reviewed Patient B's medical record and found that Patient A's prescription record was mistakenly filed therein, the doctor immediately stopped prescribing the drug and explained the situation to Patient B. After a physical examination on Patient B, it was confirmed that Patient B was in stable condition and showed no signs of adverse effect caused by the drug. Patient B was discharged on May 23, after recuperation. The hospital also confirmed that no other patient was affected in this incident.
On the other hand, as Patient A's prescription record was mistakenly filed in Patient B's medical record, the nurse of PWH was unable to locate the prescription record in Patient A's medical record. The nurse then informed the doctor who subsequently wrote a new prescription to Patient A. Under such circumstances, Patient A's condition was not affected in this incident.
Both PWH and SH attached great importance to this incident and have already made a report of this incident to the Cluster Management through the Advanced Incident Reporting System. Upon investigation, it was revealed that the incident was caused by negligence of individual staff. The staff involved were admonished by their hospital while the frontline healthcare staff were reminded to keep and check patients' medical records and prescription records in a proper manner and strictly observe the relevant prescription guidelines. In case any problem or any loss of record is found, a report must be instantly made to the officer-in-charge in order to heighten staff's vigilance and to take necessary follow-up actions.
(b) to (e) The New Territories East Cluster implemented the revised "3 Checks and 5 Rights" procedures since April 2006. From May 2006 to April 2007, the number of incidents of wrong dispensation of medicine by nurses occurred in the public hospitals under the Cluster was 71, while that occurred in the 12 months before (i.e. April 2005 to March 2006) was 106. This reflects a drop by 31% in the occurrence of such incidents after implementation of the revised procedures. For 2004 and before, since HA did not systematically record the number of incidents of wrong dispensation of medicine by nurses, accurate statistics is not available.
HA has all along attached great importance to the proper handling of drugs and implemented a number of measures in this regard in addition to making improvements to the design of the current system. These included (i) formulation of a set of nursing rules on verification of patients' identity in 2004 and a set of self-evaluation guidelines on medication safety in 2005 in a bid to heighten frontline staff's vigilance in verifying patients' identity; (ii) since April 2007, healthcare staff can make a report of medication incident through a one-stop electronic Advanced Incidents Reporting System and at the same time study the causes and draw useful lessons from such incidents; (iii) making improvements to the design of identification bracelets for in-patients by using larger fonts to show patients' important identifying particulars to facilitate verification of patients' particulars by healthcare staff.
The "3 Checks and 5 Rights" procedures are the basic rules and operational procedures in nursing activity. HA has all along made efforts to enhance the training for all frontline healthcare staff so as to heighten their vigilance. As regards the introduction of an electronic procedure for dispensing drugs in hospital wards, this would involve different steps and considerations and HA is now studying the feasibility.
Ends/Wednesday, June 18, 2008
Issued at HKT 12:03
NNNN
