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The following is issued on behalf of the Hospital Authority:
The Hospital Authority (HA) today (July 29) published two regular bulletins to promote risk management among health-care professionals in public hospitals: "HA Risk Alert" and "Medication Safety Bulletin".
Important lessons on patient safety identified from root cause analysis during incident investigation are collated and shared among health-care professionals in the quarterly publication "HA Risk Alert".
The latest issue of "HA Risk Alert" reports on a case of local anaesthetic being injected into the wrong eye; a case of catheterization performed on the wrong patient; three cases of retained gauze, gauze fragment and sponge fragment; and four cases of patient suicide. Following in-depth root cause analyses of incident investigation, recommendations are made and shared in this publication to avoid similar events in future.
"Medication Safety Bulletin" (MSB) will change its nature from this issue onwards. MSB will serve as an educational bulletin for sharing and promoting medication safety while the medication incident statistics will be shared in "HA Risk Alert". Contents of this issue include:
* Implementation of TALL man lettering for look-alike and sound-alike (LASA) names; and
* Sharing the potential risk related to local and global LASA drug names and good practices in hospitals to manage such risk.
MSB is published every six months, while the publication date will be changed to the last Fridays of November and May from the next issue.
Furthermore, the HA today also released the "Half-yearly Report on Sentinel Events and Serious Untoward Events" covering the six months from October 1, 2010, to March 31, 2011. During the reported period, there were a total of 23 sentinel events (SEs) and 47 serious untoward events (SUEs).
The 11 cases of death of inpatient from suicide accounted for the largest number of SEs, while the second category of SEs was retained instruments or other material after surgery or interventional procedure, accounting for nine cases. There were also two cases of surgery or interventional procedures involving the wrong patient or body part.
Out of the 47 reported SUEs, 42 were related to medication error and five involved patient misidentification. Ten cases had major or moderate consequences and 37 cases were minor or insignificant.
The "Half-yearly Report on Sentinel Events and Serious Untoward Events" will be published annually starting from the next issue. The above three publications on risk management released today by the HA have already been posted on the web for sharing with health-care professionals. Members of the public are also welcome to browse the following links:
* "HA Risk Alert": www.ha.org.hk/riskalert
* "Medication Safety Bulletin": www.ha.org.hk/msb
* "Report on Sentinel Events and Serious Untoward Events": www.ha.org.hk/report/sentinel_event
Ends/Friday, July 29, 2011
Issued at HKT 18:42
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