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The following is issued on behalf of the Hospital Authority:
The latest quarterly issue of "HA Risk Alert" has been published today (January 24) 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.
The current issue of "HA Risk Alert" reported five cases of retained gauze or instruments, three cases of patient suicide, and one case of an unconnected oxygen delivery tube for the ECMO system (external heart-lung machine). Among the reported serious untoward events, there were 22 medication incidents and one case of patient misidentification. Subsequent to in-depth review and root cause analyses of incident investigations, important lessons on patient safety were identified, and recommendations have been made and shared in this publication to avoid similar events in future.
Furthermore, the HA also released the Annual Report on Sentinel and Serious Untoward Events covering the 12 months from October 1, 2011, to September 30, 2012, which was discussed and endorsed by the HA Board today.
The Board members noted that the HA Sentinel Event Policy was introduced in October 2007 and there was subsequent revision of the policy in January 2010 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, there were a total of 34 sentinel events reported during the period. There were fewer cases when compared with the total of 44 cases over the previous year. It was noted that the decrease was accounted for by the reduction of 10 cases of patient suicide as compared with the year before.
Serious untoward events are unexpected occurrences which did not cause death or permanent harm to patients but would have the potential to do so if there had not been timely intervention. During the year, 102 serious untoward events were reported, with 92 and 10 events related to medication error and patient misidentification respectively.
The Annual Report on Sentinel and Serious Untoward Events can be accessed by health-care workers and the public at www.ha.org.hk/report/sentinel_event, while "HA Risk Alert" has been distributed to the health-care professionals in public hospitals for continuous quality improvement purposes and can be accessed by the public at www.ha.org.hk/riskalert.
Ends/Thursday, January 24, 2013
Issued at HKT 16:10
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