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The following is issued on behalf of the Hospital Authority:
Alice Ho Miu Ling Nethersole Hospital today (July 3) released the investigation findings of a sentinel event involving an 84-year-old male patient. The hospital announced the sentinel event on April 17, 2013 and subsequently set up an Investigation Panel to investigate the incident.
The patient suffered from rifampicin-induced thrombocytopenia in October 2011 and was transferred to the Department of Orthopaedics and Traumatology of Alice Ho Miu Ling Nethersole Hospital on March 7, 2013 for further treatment due to infected dislocation of right Austin Moore arthroplasty. An operation for wound debridement and removal of prosthesis was performed on March 8, 2013. As the infection could not be cleared, the attending doctor prescribed the patient with the antibiotic rifampicin on April 11. The patient was administered a total of two doses of rifampicin on April 11 and 12.
The patient's condition deteriorated on April 12 with a lowered haemoglobin level and platelet count and elevated white cell count. Treatments including packed cells and platelet transfusions were given. The doctor explained to the patient's family that the possible causes of thrombocytopenia could be due to the prescription of rifampicin or severe sepsis induced by wound infection. The patient's haemoglobin level and platelet count improved after transfusions, but the patient further deteriorated with hypotension and respiratory failure. The patient finally succumbed on April 14.
According to the investigation report, "Known Drug Allergy to Platelet" was mentioned in the patient's case notes, medication administration records and automated print-out of Clinical Management System Allergy/Alert information sheet. However, details of "Adverse Drug Reaction to Rifampicin" including the severity and possible outcome were not indicated. Also, the two prescribing doctors were not alerted to the significance of the patient's adverse drug reaction to rifampicin. The hospital has met the deceased's family to explain the details of the investigation and expressed its deep apology and condolences to the family. The hospital will continue to keep close contact with the family and provide assistance.
The Panel has made several recommendations to prevent recurrence of a similar incident:
1. To reinforce training of clinical staff on the importance of checking "Adverse Drug Reaction", the incident will be shared with doctors, nurses and pharmacists at the Hospital Medication Safety Forum. The hospital will further raise staff awareness through Risk Alert in the electronic poster and giving hard copy leaflets to all clinical staff.
2. The on-duty pharmacist receives the detailed information on severe "Adverse Drug Reaction" from the Computerised Automatic Refill System and the Clinical Management System alerts the doctor-in-charge of the information through phone communication, and needs additional confirmation with the doctor's supervisor urgently if change of medication is not made. This has already been implemented.
3. In the long run, information provided for "Adverse Drug Reaction" that both the drug name and also its severity should be indicated in Allergy/Alert information sheet from Clinical Management System.
The hospital has accepted the report from the Investigation Panel and will follow up on the recommendations. The report has been submitted to the Hospital Authority Head Office. The case has been reported to the Coroner, and assistance will be provided to facilitate the Coroner's investigation.
The hospital is deeply grateful to the Chairman and members of the Investigation Panel for their investigation efforts.
Ends/Wednesday, July 3, 2013
Issued at HKT 19:06
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