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The following is issued on behalf of the Hospital Authority:
The 24th issue of "HA Risk Alert" was published today (January 27) by the Hospital Authority (HA) as a risk management and communication initiative to further strengthen the reporting and monitoring of adverse incidents in public hospitals.
In the foreword of the latest issue, the Editor-in-Chief of the publication, HA Consultant (Quality & Risk Management) Dr Lui Siu-fai, pointed out that this issue takes the sentinel event reporting to the end of the fourth year since the sentinel event policy was introduced on October 1, 2007. He stressed that health-care colleagues in future need to enhance the five S's of patient safety, which are safety culture, safe design, safe practice, staff engagement, and sharing and learning, to make the hospital a safer place for patients and colleagues to work in.
The reported sentinel events analysed in this issue include one case of fatal medication, one case of blood transfusion with red cells of the incorrect blood group, one case of incorrect procedure performed and five cases of retained segment of consumables or retained gauze. It also highlights the key learning points on one of the five in-patient suicide cases in the reported period. Among the 29 reported serious untoward events, there were 27 medication incidents and two cases of patient misidentification. Subsequent to in-depth root cause analyses investigation, recommendations are made and shared in this publication to avoid similar events in future.
The publication also presents the statistics of medication incidents in the first half-year of 2011.
The publication has been distributed to all health care professionals in public hospitals for continuous quality improvement purposes. It can also be accessed by the public at www.ha.org.hk/riskalert.
"HA Risk Alert" is published on a quarterly basis and posted on the HA website every last working Friday in the months of January, April, July and October. The next issue will be published on April 27.
Ends/Friday, January 27, 2012
Issued at HKT 17:44
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