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The following is issued on behalf of the Hospital Authority:
The ninth issue of "HA Risk Alert" is published today (March 27) by the Hospital Authority as a risk management and communication initiative to further strengthen the reporting and monitoring of adverse incidents in public hospitals.
In a special message for the healthcare professionals in this issue, Chief Manager (Nursing) Ms Sylvia Fung remarked that having staff as advocates of safety and guard against risk was the best way to identify and rectify loopholes in the system. She said it was never easy to face the aftermaths of medical incidents, "it needs courage from oneself and support others to establish and sustain the culture of open disclosure."
The latest issue of "HA Risk Alert" features a sentinel event of retained gauze after normal delivery and a case of retained instrument part after varicose vein stripping. Subsequent to in-depth root cause analyses during incident investigation, recommendations are made and shared in this publication to avoid similar events in future.
Good practices are also shared in this issue on the "time-out" process which helps prevent patient identification error; and newly introduced safe design, practice and system in reducing the risk in administration of intra-thecal chemotherapy.
Common pitfalls in local and overseas healthcare setting are also highlighted to enhance staff vigilance. Locally, healthcare professionals are reminded to manage the risk of possible exposures to case of Creutzfeldt-Jakob Disease, a fatal human neurodegenerative disorder.
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 regularly published and posted on the Hospital Authority internet website every last working Friday in the alternate (odd) month. The next issue will be published on May 29.
Ends/Friday, March 27, 2009
Issued at HKT 17:01
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