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Hospital Authority "Risk Alert" seventh issue published
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The following is issued on behalf of the Hospital Authority:

     The seventh issue of "HA Risk Alert" was published today (November 28) by the Hospital Authority (HA) as a risk management and communication initiative to further strengthen the reporting and monitoring of adverse incidents in public hospitals.

     In a special message to readers in this issue, the Cluster Chief Executive of Hong Kong West Cluster, Dr Lawrence Lai, said with the introduction of the Advanced Incident Reporting System and Sentinel Event Reporting, the HA has successfully built an open and just culture in enhancing patient safety by identifying and reporting adverse events and medical incidents, analysing causes of failures in delivery of patient care as well as formulating strategies, policies or steps to prevent or reduce their recurrence.  "With HARA, we don't have to err to learn," Dr Lai said, highlighting the value of the publication for experience sharing among frontline staff.

     The latest issue of "HA Risk Alert" featured a sentinel event of an unnecessary mastectomy due to contamination of the biopsy specimen and a case of incorrect blood transfusion for a newborn, as well as a few cases of retained instrument, device and gauze in patients.  Subsequent to in-depth root cause analyses during incident investigation, recommendations were 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 risks associated with known drug allergies, especially with the penicillin group.

     The publication has been distributed to all healthcare professionals in public hospitals for continuous quality improvement purposes.  It can also be accessed by the public at www.ha.org.hk/riskalert.

     "HA Risk Alert" is published regularly and posted on the HA website every last working Friday in the alternate (odd) month. The next issue will be published on January 30, 2009.

Ends/Friday, November 28, 2008
Issued at HKT 17:32

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