**************************************
The following is issued on behalf of the Hospital Authority:
The 31st issue of "HA Risk Alert" was published today (October 25) 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.
There were six sentinel events reported in the second quarter of 2013. The patients recovered in a case of wrong-side procedure and a case of retained medical consumables, while an adverse event of transporting a patient to another cubicle led to a fatal outcome. The reported events also included cases of patient suicide, maternal death and abduction of an infant by its mother. Subsequent to root cause analysis, recommendations have been made and shared in this publication to avoid similar events happening again in future.
During the reporting period, there were 25 reported serious untoward events, comprising 24 medication incidents and one case of patient misidentification. Among the medication incidents, two cases of overlooking known drug allergy and known adverse drug reaction and two cases of administering anticoagulants and dangerous drugs were highlighted, alongside some practical tips and good practices for minimising similar incidents.
The publication also alerted colleagues to a few cases of prescription error due to misinterpretation of symbols used in electronic Patient Records. It reminded health-care professionals of the importance in medication reconciliation and to avoid sole reliance on technology in prescribing medication.
The publication also presented the top categories of incidents reported in the Advance Incident Reporting System in the first two quarters of 2013.
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 on every last working Friday in the month of January, April, July and October. The next issue will be published on January 24, 2014.
Ends/Friday, October 25, 2013
Issued at HKT 16:41
NNNN
