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The following is issued on behalf of the Hospital Authority:
Queen Elizabeth Hospital made the following announcement today (August 25) regarding a medication incident:
On Sunday (August 23), a nurse of the postnatal ward obtained from the drug fridge in the ward a bottle of reconstituted BCG (Bacillus Calmette-Guerin) vaccine for injection to five newborns (four boys, one girl) without checking clearly the preparation date written on the bottle. Soon after administrating the vaccine, the nurse re-examined the bottle and found that the vaccine used was reconstituted on the afternoon of August 21 and it was best to be used within four hours of reconstitution. The incident was reported to the management immediately. All babies were assessed and no abnormality was detected. Detailed risk assessment was made. Despite the slim chance of germs growing in the reconstituted vaccine bottle, a microbiological test on the contents remaining in the bottle was done to rule out the risk of these babies infected by other germs.
Two meetings were arranged between the hospital management and parents of the five babies on the day of the incident and yesterday to thoroughly explain the incident and the follow-up actions. The hospital had expressed sincere apologies to the parents concerned. All five babies are now in satisfactory condition. Four of them were discharged yesterday while one baby is still hospitalised due to neonatal jaundice problem. The hospital will closely monitor the condition of the babies and follow-up appointments at Specialist Outpatient Clinics have been arranged.
The hospital is deeply concerned about the incident and has reported to the Hospital Authority via the Advanced Incident Reporting System. The investigation found that the cause of the incident was solely a human error. An individual staff member had failed to comply with the medication checking guidelines to clearly check the reconstitution date written on the vaccine bottle before vaccination, hence overlooking that the contents has expired its best consumption date. The staff member concerned has been reminded to duly observe the related procedures and will be closely supervised at work for a definite period of time. Appropriate action will be taken according to the human resources policies of the Hospital Authority.
In recent years, the hospital has promulgated the Years of Safety campaign and is committed to enhance patient safety through systematically reviewing the areas related to patient safety including both clinical systems and human factors.
The hospital would like to express sincere apologies again to the families of the babies and assured that staff members will learn from this incident to avoid a recurrence in the future.
Ends/Tuesday, August 25, 2009
Issued at HKT 16:26
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