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The following is issued on behalf of the Hospital Authority:
The sixth issue of ¡§HA Risk Alert¡¨ is published today (September 26) by the Hospital Authority, marking the first anniversary of implementing the Sentinel Event Policy in October 2007 as a risk management and communication initiative to further strengthen the reporting and monitoring of adverse incidents in public hospitals.
In the foreword of the bi-monthly publication, authority chairman Mr Anthony Wu said it was very encouraging to see the paradigm shift that had taken place in the past year. ¡§The Sentinel Event Policy we have introduced enables us to better manage medical incidents. We have established a learning and sharing environment that helps us embrace the lessons that can be learned from every incident and prevent it from recurring.¡¨
He thanked staff members for their contributions to the success of these initiatives which enabled the Hospital Authority to make tremendous advances in this new era of patient safety.
The latest issue of ¡§HA Risk Alert¡¨ features two sentinel events: a case of mislabelling of specimen leading to unnecessary transfusion and a case of implantation of incorrect intraocular lens. Subsequent to the in-depth root cause analyses during incident investigation, recommendations are made and shared in this publication to avoid similar events in future.
Common pitfalls in local and overseas healthcare settings are also highlighted to enhance staff vigilance. Locally, healthcare professionals are reminded of the risk associated with the use of ventilators while overseas initiatives in reducing the risk of intrathecal chemotherapy following a few unfortunate events are also featured.
The publication has been distributed to all health care professionals in public hospitals for continuous quality improvement purpose. It can also be accessed by the public at http://www.ha.org.hk/riskalert
The "HA Risk Alert" is published and posted on the HA internet website every last working Friday in the alternate (odd) month. The next issue will be published on November 28.
Ends/Friday, September 26, 2008
Issued at HKT 16:22
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