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The following is issued on behalf of the Hospital Authority:
Regarding the investigation on the incident of a wrong breast biopsy specimen of a patient at North District Hospital (NDH) in July this year, a hospital spokesperson makes the following announcement today (November 20):
Following the incident, an investigation panel was appointed to investigate the incident and to make recommendations on prevention of similar incidents. The members of the panel included: Chairman of Central Co-ordinating Committee, Pathology, Hospital Authority, Dr Ng Wing Fung; Chairman of Central Co-ordinating Committee, Surgery, Hospital Authority, Dr Francis Mok Pik Tim; Chairman of Department of Anatomical & Cellular Pathology, Chinese University of Hong Kong, Professor Ng Ho Keung; and Senior Nursing Officer, Patient Safety and Risk Management, Hospital Authority Head Office, Ms Becky Ho Pui Yee. The investigation report has been submitted to the Hospital Authority Head Office.
The incident was related to the contamination of the breast core biopsy specimen of the index patient with a piece of malignant core tissue from another patient. This led to a wrong type of breast surgery performed for the index patient.
After extensive deoxyribonucleic acid (DNA) analysis, the panel identified the source of the malignant core tissue. It belonged to a patient who had breast core biopsy done in the same surgical ward 14 days earlier than the index patient. That patient had been offered appropriate treatment for her breast condition.
The panel was able to conclude that the contamination of the breast core biopsy specimen of the index patient most likely occurred at the surgical ward. Both medical and nursing staff were involved in the processing of the core tissue biopsy. The factors that had contributed to the incident included:
(a) more than one formalin specimen bottles had been used in the biopsy procedure of the source patient;
(b) that the specimen bottle(s) was (were) not immediately labelled and left behind at the bedside after the procedure, and one of them was presumed to be unused, and;
(c) that the presumed unused formalin bottle was not discarded but was retained for future use, and was used for collecting the biopsy specimens of the index patient.
Based on the findings, the panel made the following key recommendations:
- A staff member should be designated to be responsible for the labelling of specimen after each biopsy procedure.
- The hospital should reinforce the importance of immediate labelling of the specimen after the biopsy procedure.
- Any opened and unused specimen bottles after the biopsy procedure should be discarded.
- Hospital management may consider supplying the formalin-filled specimen bottles with breakable seal. Staff should not use any specimen bottle with broken seal.
- Only one nursing staff should be designated to assist throughout each biopsy procedure.
- It is desirable to have better documentation of biopsy procedures. This includes the identity of doctors involved, the number of pass performed and the number of core tissue obtained during the biopsy procedure.
NDH expressed its gratitude to the panel members and accepted the recommendations made in the panel's report. Immediately after the incident, the hospital had already reviewed the relevant operational procedures and seriously notified the relevant departments and staff to strictly follow the relevant protocols and guidelines to prevent the recurrence of similar incidents. The health condition of the concerned patient is stable. The hospital has again expressed its deepest apology and explained the investigation results and findings to the patient's relatives. The hospital will continuously provide appropriate care to the patient and render necessary assistance to her. The hospital management will offer guidance and counselling to the concerned staff and further review and implement the recommendations made by the panel, to strengthen the risk management and to improve the standards of patient care and services of the hospital.
Ends/Thursday, November 20, 2008
Issued at HKT 19:00
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