Traditional Chinese Simplified Chinese Email this article news.gov.hk
HA releases publications on risk management
*******************************************

The following is issued on behalf of the Hospital Authority:

     The Hospital Authority (HA) today (January 28) published two regular bulletins to promote risk management among healthcare professionals in public hospitals - the "HA Risk Alert" and the "Medication Safety Bulletin".

     Important lessons regarding patient safety identified from root cause analysis during incident investigations will be collated and shared among healthcare professionals in the bi-monthly publication "HA Risk Alert".

     The latest issue of "HA Risk Alert" reports on a case of inadvertent reduction of drug dosage, a case of retained gauze and six cases of patient suicide. Subsequent to in-depth root cause analyses of incident investigations, recommendations are made and shared in this publication to avoid similar events in future.

     With a particular focus on medication issues, the Medication Safety Bulletin, previously known as the "Medication Incident Reporting Programme" bulletin, was first established in 1994 as a continuous quality improvement initiative through regular case sharing and statistical analysis of reported incidents. In this latest issue, the bulletin highlights six cases for sharing with recommendations to prevent recurrence of incidents of a similar nature. The bulletin is published every six months.

     HA has also released the Annual Report on Sentinel Events covering the 12 months from October 1, 2009 to September 30, 2010, which was discussed and endorsed by the HA Board yesterday (January 27).

     The Board members noted that the HA Sentinel Event Policy was introduced in October 1, 2007 to further strengthen the reporting, management and monitoring of serious medical incidents in public hospitals. The first Annual Report was published in January 2009.

     In this year's report, a total of 33 sentinel events are reported during the period, a drop for the second year running. There were 40 and 44 events respectively last year and the year before (2009).  It is noted that the drop is mainly due to a reduction in reported suicide cases, which used to top all categories of reported events.

     HA Chief Executive Dr Leung Pak-yin highlighted that commencing January 1, 2010, hospitals are required to report serious untoward events. "The main purpose is to mitigate risks and improve patient safety by further enhancing staff awareness to clinical risk and stimulate innovative thinking for safe designs, processes and practices."

     Serious untoward events are unexpected occurrences which have not caused death or permanent harm to patients but which have the potential to do so if not prevented in time. During the year, 81 serious untoward events were reported, with 72 events related to medication error and nine to patient misidentification.

     The Annual Report on Sentinel Events can be accessed by health care workers and the public at www.ha.org.hk/report/sentinel_event, while the two risk management bulletins have been distributed to healthcare professionals in public hospitals for continuous quality improvement purposes, and can be accessed by the public at www.ha.org.hk/riskalert and www.ha.org.hk/msb.

Ends/Friday, January 28, 2011
Issued at HKT 18:01

NNNN

Print this page