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Following is a question by the Hon Kwok Ka-ki and a written reply by the Secretary for Food and Health, Dr York Chow, in the Legislative Council today (July 9):
Question:
The Hospital Authority (HA) launched the Advanced Incident Reporting System in 2006 and has implemented a Sentinel Event policy since October 2007 to strengthen the reporting, management and monitoring of sentinel events in public hospitals. HA also makes public these events in its internal newsletter to alert frontline medical staff to prevent the recurrence of the events. In this connection, will the Government inform this Council whether:
(a) it knows what mechanism HA has in place to ensure that frontline medical staff report medical incidents accurately; and
(b) it will consider requiring, through administrative instructions or even by legislation, that HA must not disclose the places of the incidents and the names of the medical staff involved when making public the medical incidents concerned, so as to encourage medical staff to report such incidents proactively?
Reply:
Madam President,
(a) The Hospital Authority (HA) has put in place an established mechanism and guidelines for medical staff to report medical incidents and take follow-up actions. Under the existing mechanism, hospital clusters will make immediate reports of medical incident to the HA Head Office through HA's internal Advanced Incident Report System (AIRS). In addition, HA has since October 2007 implemented a Sentinel Event Policy to strengthen the reporting, management and monitoring of sentinel events in public hospitals, so as to further enhance patient safety. Under the above Policy, hospital clusters are required to report via the AIRS any medical incidents classified as sentinel events within 24 hours upon awareness of their occurrence. They should at the same time handle the incident promptly in accordance with the established procedures so as to minimise the harm caused to the patient and provide support to the staff involved in the incident. The HA Head Office is responsible for monitoring and coordinating the handling of sentinel events and implementation of initiatives for promoting patient safety at an organisational level.
As to follow-up actions on medical incidents, the hospitals concerned will investigate the causes of the sentinel events and take follow-up actions. They are also required to submit a report on the event to the HA Head Office. HA will improve the relevant systems and working procedures where necessary, with a view to avoiding recurrence of similar incidents in future. Through the training provided by HA and the internal newsletter "Risk Alert" published by HA, the staff of different clusters could make reference to and draw on the experience in handling sentinel events.
(b) As a public body, HA has the responsibility to make public the causes and details of medical incidents in a transparent and open manner. This would help HA fosters mutual trust and a respectful relationship with the public. In the case of serious medical incidents, HA may disclose the places where the incident took place as well as the grade and rank of the medical staff involved when making public the details of the medical incidents. However, the identity of the medical staff will not be disclosed. Under the principle of being accountable to the public in a transparent and open manner, we consider the practice of not disclosing the places where medical incidents occurred is not feasible and preferable. HA will endeavour to maintain the high quality of services and at the same time promote a learning culture among its staff so as to encourage them to communicate with patients and their families professionally under the principle of mutual trust and respect and explain to them the causes and consequences of medical incidents, to report medical incidents accurately and reduce the chance of mistake.
Ends/Wednesday, July 9, 2008
Issued at HKT 12:21
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