************************************************************
The following is issued on behalf of the Hospital Authority:
The Independent Investigation Panel (The Panel) appointed by the Cluster Chief Executive of Hong Kong West Cluster (HKWC) has completed its investigation into the medication incident in Tung Wah Hospital (TWH) on April 11, 2009 where wrong drug dosage of Phenobarbitone (PB) were given to six in-patients of the hospital. One of the patients passed away and the cause of her death was under investigation by the Coroner. Of the five other patients affected by the medication incident, the clinical condition of three has remained stable to date while two had already been discharged from the hospital.
The investigation report has been submitted to the Hospital Authority Head Office today (June 16).
The Panel concluded that the main causes of the incident were as follows:
(1) The supplier of Phenobarbitone had delivered a wrong bottle of Phenobarbitone to TWH
The hospital had requested for a supply of three bottles (1,000 tablets per bottle) of PB 30mg. The supplier had delivered 3 bottles of Phenobarbitone to the hospital including one bottle containing 1000 tablets of Phenobarbitone 60mg by mistake.
(2) There was difficulty in identifying the different dosage strength of Phenobarbitone
All along, TWH had only requested for and stocked up single dosage strength (30mg) of Phenobarbitone. Hence, staff in the Pharmacy had not expected the delivery of a bottle of PB (60mg) from the supplier. Since all 3 bottles of PB received by the TWH Pharmacy were identical in shape, height and colour, the staff in the Pharmacy had consequently failed to detect the discrepancy in dosage strength which was only shown on the label of each bottle.
(3) The wrong dosage strength was not detected during pre-packaging process
During the ˇ§pre-packaging processˇ¨, the pharmacy staff had to unpack the bottle of 1000 tablets of PB and to re-package and place the PB tablets into individual bottles of 20 tablets for dispensing to wards for use. In the process, the staff was only required to enter the drug code into the pre-pack log book manually. Since the drug name and strength of PB was not verified in the process, the staff was unable to detect the discrepancy in dosage strength shown on the PB 60mg bottle.
(4) Pharmacy Staff noted difference in colour of Phenobarbitone 60mg but failed to recognize the difference in dosage strength
Although three staff members in Pharmacy had conducted different steps of checking the bottle of PB 60mg during the pre-packaging process, they were unable to detect the discrepancy in dosage strength shown on the label of the bottle. The staff member who conducted the final check noticed that the colour of the PB (60mg) tablets (pink) was different from the previous ones (green). Yet, he somehow perceived that the PB tablets were 30 mg in strength. An additional ˇ§appearance changedˇ¨ label was affixed to the bottle after pre-packaging to inform ward staff of the colour change.
The Panel noted that both the TWH Pharmacy and Drug Store were heavily engaged in the drug recall and checking of pharmaceutical products from March to April 2009 which may have hampered the alertness and vigilance of staff in conducting proper medication verification procedures. Moreover, pharmacy staff was used to accepting change in appearance of drugs of the same compound and dosage which was not uncommon because of the occasional change of suppliers of various generic drug products in HA. With the ˇ§appearance changedˇ¨ label affixed to the bottles of PB in this medication incident, the alertness of the ward nurses in verifying the dosage strength of the supplied drug was also hampered. Ward nurses were therefore misled into believing that the PB supplied by the Pharmacy was 30 mg in dosage, despite the change in colour of the drug.
The Panelˇ¦s recommendations are summarized as follows:
1. To improve the drug pre-packaging procedures and to reduce medication errors, clear role delineation, job assignment, accountability and guidelines for all pharmacy staff in TWH should be formulated and put into practice.
2. To enable Pharmacy staff to focus on performing high risk tasks (failure of which may lead to incorrect drug verification or pre-packaging error) during sudden substantial increase in Pharmacy workload, a Surge Response Plan incorporating service re-prioritization or re-arrangement in TWH Pharmacy should be formulated .
3. To eliminate the high volume repetitive tasks of drug repackaging, system improvement measures, such as supply of smaller pack sizes by the supplier or systems automation should be considered, and the feasibility of establishing a central drug pre-packaging facility for all HA hospitals should be explored.
4. To reduce errors in the supply of drugs and to minimize the frequent change in size and shape of drug which may lead to drug identification error, pharmaceutical companies and suppliers should be advised to establish distinguishable features for container, packing, colour for easy differentiation of the drug and its dosage as far as possible; and the feasibility of setting up a corporate reference list containing the latest appearance of drugs supplied for use in HA hospitals to facilitate proper drug identification should be explored.
TWH wishes to thank the Panel members for their dedication and effort in conducting the investigation and finalizing the report. The hospital has also accepted the recommendations made by the Panel. Immediately after the incident, the hospital had already reviewed its operational procedures, and had implemented a number of improvement measures to prevent recurrence of similar medication incidents in future. The hospital had explained the investigation result and findings to the patients and their families this afternoon. As a follow up of the Panelˇ¦s investigation findings and in accordance with the Hospital Authorityˇ¦s Human Resources Policies, HKWC has set up a disciplinary investigation panel to look into the performance of the staff involved in the medication incident. Appropriate disciplinary actions against individual staff would be taken with reference to the Panelˇ¦s investigation findings and recommendations.
Ends/Tuesday, June 16, 2009
Issued at HKT 21:01
NNNN
