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The following is issued on behalf of the Hospital Authority:
Regarding a case of misidentification of two babies, the spokesperson of Queen Elizabeth Hospital (QEH) made the following announcement today (August 17):
According to the prevailing protocol on patient identification for new born babies in the Obstetrics & Gynaecology Department, a handwritten identification bracelet must be put on the wrist of a baby in front of the mother in the labour room; a 2D barcode identification band is added to the ankle of a baby in the postnatal ward upon admission. The bracelet must be checked when applying the band and putting the baby back to the cot. Each shift of the ward staff must check that the wrist bracelet and ankle band are intact and verify the information on them. Besides, ward staff would check the information of the wrist bracelet and ankle band of the babies in front of the mothers before discharge.
Initial information indicated that, in this incident, correct procedure was carried out in the labour room. However, in the postnatal ward, the identification bands for the two babies were not applied immediately and individually. The babies were put to the wrongly labelled cot from the incubators. The ward staff did not check the information on the wrist bracelet when applying the ankle band. The ward staff of all shifts did not verify the information on the wrist bracelet against that on the ankle band.
Immediately after this incident, the hospital has taken the following improvement measures:
- Labour room staff will put a handwritten identification band on a baby's left foot instead of a bracelet on the left wrist, lest the bracelet drops off when he/she shrinks;
- Postnatal ward staff will put a 2D barcode identification band on a baby's right foot in front of the mother;
- Retrain the staff concerned and monitor their performance;
- Remind all staff to strictly follow the patient identification protocol;
- Carry out regular auditing;
- Form an investigation panel to investigate and follow up on the case.
The hospital would like to express apologies to the parents of the two babies again and has set up an investigation panel for the incident for submitting a report in four weeks to the Hospital Authority Head Office and the Food and Health Bureau. The panel is chaired by Dr Cheung Kai-bun, Chairman, Central Coordinating Committee (Obstetrics & Gynaecology) and Chief of Service (Obstetrics & Gynaecology), Tuen Mun Hospital with members including Mr John Wu, BBS, MH, Hospital Governing Committee Member, Queen Elizabeth Hospital, Ms Sylvia Fung, Chief Manager (Nursing)/Chief Nurse Executive, Hospital Authority, Dr Wong Kit-fai, Cluster Chief of Service (Pathology), Kowloon Central Cluster and Ms Eva Liu, Cluster Coordinator (Risk Management), Kowloon Central Cluster.
Ends/Monday, August 17, 2009
Issued at HKT 20:11
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