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The following is issued on behalf of the Hospital Authority:
The 27th issue of "HA Risk Alert" was published today (October 26) by the Hospital Authority (HA) as a risk management and communication initiative to further strengthen the reporting and monitoring of medical incidents in public hospitals.
In the foreword of the latest issue, the Cluster Chief Executive of Hong Kong East Cluster, Dr Lau Chor-chiu pointed out the importance of sharing of good practices in patient safety. "Learning from factors contributing to the occurrence of near misses or incidents and taking actions to control or eliminate their underlying root causes are the main keys to improving patient safety." Dr Lau added that highly effective teamwork and a culture of speaking up are crucial to enhancing patient safety in frontline daily work.
The reported sentinel events analysed in this issue highlight three cases of wrong site surgery performed, four cases of retained segment of consumables or retained instruments, and two cases of maternal death or serious morbidity associated with labour or delivery. It also highlighted the key learning points of four patient suicide cases in the reported period. Among the 26 serious untoward events reported, there are 23 medication incidents and three cases of patient misidentification. Subsequent to the review by investigation teams, recommendations are made and shared in this publication with the intention of avoiding similar events in future.
The publication also presents the top reported categories of incidents in the Advanced Incident Reporting System in the first two quarters of 2012.
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 is posted on the HA website every last working Friday in the month of January, April, July and October. The next issue will be published on January 25, 2013.
Ends/Friday, October 26, 2012
Issued at HKT 17:37
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