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The following is issued on behalf of the Hospital Authority:
The Hospital Authority (HA) Board discussed at its open meeting today (July 10) the first Progress Report on Sentinel Events covering the six months from October 1, 2007, to March 31, 2008.
Members noted that the HA Sentinel Event Policy was introduced in October 2007 to further strengthen the reporting, management and monitoring of serious medical incidents in public hospitals. HA Chief Executive Mr Shane Solomon said that the entire HA will learn from the reported events and change systems and processes for greater patient safety.
During the reporting period, a total of 23 sentinel events were reported, among which the most common event was patient suicide, which also resulted in 12 cases of patient death.
There were also five events with retained instruments or other material after surgery or interventional procedure which required re-operation or further surgical procedure. Another three cases involved the wrong patients or body parts during surgery or interventional procedures. All eight patients recovered without permanent injury.
：Important lessons learned from the reported events have been shared amongst all HA staff in the bi-monthly newsletter．HA Risk Alert・ and appropriate risk reduction strategies are being implemented to reduce the recurrence of similar incidents,； added Mr Solomon.
Board members also noted that a series of improvement activities would be undertaken to further enhance patient safety. They include:
* further clarification of some of the reporting criteria for the Policy;
* enhancement of some of the supporting processes, such as the methodology for conducting effective root cause analysis and application of open disclosure;
* implementation of effective risk reduction measures; and
* further enhancement of safety culture through strengthening proactive, sharing and learning, and．Just・ culture. A HA-wide survey on patient safety culture will also be conducted to enhance the understanding of the organisational factors that have an impact on patient safety.
The Progress Report on Sentinel Events can be accessed by health care workers and the public at www.ha.org.hk/riskalert.
Ends/Thursday, July 10, 2008
Issued at HKT 18:44
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