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The following is issued on behalf of the Hospital Authority:
The Hospital Authority (HA) Board discussed at its Administrative and Operational Meeting today (July 29) the Half Year Report on Sentinel Events covering the six months from October 1, 2009, to March 31, 2010.
The Board members noted that the HA Sentinel Event Policy introduced in October 2007 and revised in January 2010 has guided all HA hospitals to focus on patient safety and to undertake thorough evaluation of patient care processes and service performance in a transparent way.
HA Chief Executive Mr Shane Solomon said that in an effort to widen the scope of risk identification, the Sentinel Event Policy was recently reviewed and revised to include a category of Serious Untoward Events.
The Serious Untoward Event category, which is an extension of the Sentinel Event Policy, is to further enhance the reporting and learning culture - to learn from adverse events which fortunately did not cause any serious permanent harm to the patients, but could have led to permanent harm or death of the patient had it not been discovered and rectified in time or had its worst consequences materialised.
"Important lessons learnt from the reported events have been shared among all HA staff in the bi-monthly newsletter 'HA Risk Alert' and appropriate risk reduction strategies are being implemented to reduce the recurrence of similar incidents," added Mr Solomon.
During the reporting period (October 1, 2009, to March 31, 2010), a total of 20 sentinel events were reported, and 22 serious untoward events from January 1 to March 31, 2010.
The most common sentinel event was retained instruments or other material after surgery or interventional procedure which required re-operation or further surgical procedure. There were 10 incidents in this category recorded during the period. The second and third most common categories were death of an in-patient from suicide, and surgery or interventional procedures involving the wrong patients. Five and three cases were recorded respectively.
There were also two pregnant patients with high antenatal risk who succumbed during delivery. Both mothers failed to respond to active resuscitation.
Among the 22 serious untoward events reported, 15 cases were due to medication errors and seven cases due to patient misidentification.
The Half Yearly Report on Sentinel and Serious Untoward Events can be accessed by health care workers and members of the public at www.ha.org.hk/report/sentinel_event.
Ends/Thursday, July 29, 2010
Issued at HKT 17:45
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