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The following is issued on behalf of the Hospital Authority:
The spokesperson for United Christian Hospital (UCH) today (October 8) made the following announcement on an investigation report into a pathology report deviation incident.
The independent expert panel was appointed by UCH after the announcement of an incident relating to pathology report deviation on August 11. The expert panel has completed the investigation with a number of recommendations on improvement measures. The report has also been submitted to the Hospital Authority (HA) Head Office and UCH. UCH has accepted the recommendations made by the panel and implemented a number of improvement measures immediately to enhance patient safety and to prevent recurrence of similar incident in future.
The independent expert panel, comprising pathology experts, has interviewed all the staff concerned and reviewed all pathology reports with deviations and relevant pathology slides in the past eight weeks, the spokesperson said. The panel has also reviewed thoroughly all relevant materials such as duty arrangements, workflow procedures and quality assurance mechanisms of the pathology department.
During a pathology department internal meeting held in late May for routine review of pathology reports, three reports issued by the same pathologist were found to be inaccurate. The pathology department decided to proactively review all 2,153 pathology reports issued independently by the pathologist concerned since October 2013. The department identified 118 reports requiring content revision by early August. Of the reports which required revision, 17 of them involved misdiagnosis, leading to minor adjustment of treatment plans for 15 patients and significant revision in treatment plan for two patients.
The spokesperson said, "The investigation report pointed out that making pathological diagnosis requires high a level of attentiveness. The occurrence of the incident was mainly due to a personal performance issue. The discrepancies made in the pathology reports were largely due to lapses of sustained vigilance. The investigation report suggested the department should keep the pathologist concerned working under close supervision of a senior pathologist, while no independent reporting should be allowed. The pathology department should arrange remedial training with a focus on areas of weakness for the pathologist concerned."
The investigation has considered other information provided by the department such as workload, work allocation and duty arrangement of specific doctors and found that they did not contribute to the incident. The investigation confirmed that UCH's proactive measure to review all pathology reports issued by the pathologist concerned was valid and justified, while proving the effectiveness of the department's quality management measure in identifying this incident.
Besides, the panel agreed that UCH has implemented timely follow-up actions for the 17 patients that require change in clinical management plan after open disclosure of the incident. The panel also reviewed and agreed the causes of death of the seven cases identified were all due to their serious underlying diseases, and were unrelated to any erroneous diagnosis in the pathology reports.
In analysing the 118 reports with deviations, it is evident to the panel that no false-positive misdiagnosis was found. No patient had thus received unnecessary treatment. The panel concluded that the discrepancies found in the 118 reports mainly included false-negative misdiagnosis and contained inadequate or incorrect information.
The panel noted that it was a major undertaking for the department to review 2,135 pathology reports. A lot of follow up action was needed, such as to inform clinicians to revise clinical management plans. However, the panel opined that the reporting of the incident to the hospital management should not have been delayed until the end of the review process.
The investigation panel has made the following recommendations:
* An appropriate system should be enforced to monitor the performance of trainees; targeted coaching and training should be given to trainees with a track record of unstable performance; the utmost importance of sustained vigilance should be emphasised to every trainee via various channels.
* Communication between hospital management and the pathology department should be enhanced to improve the effectiveness of incident management.
* A clear reporting line and review mechanism should be developed to strengthen co-ordination among departments involved and to enhance the efficiency of the incident management process, particularly for incidents that may have a major impact on patient care.
The spokesperson said that UCH has accepted the findings and recommendations made in the investigation report. UCH has taken a number of immediate measures to enhance patient safety and to prevent recurrence of similar incident again. The measures are as follows:
* The pathology department has decided to stop the pathologist concerned from issuing reports independently; the department will arrange for a senior pathologist to closely supervise the pathologist concerned; remedial training, with a focus on areas of weakness, will be arranged for the pathologist concerned to enhance the quality of diagnosis.
* The pathology department has implemented a mentoring system. Every trainee in the department will be assigned a senior pathologist "mentor", who will provide one-on-one coaching and assistance to the trainee. When trainees come across difficulties at work or in training, support can be given promptly.
* The pathology department will enhance the case meeting mechanism with other clinical departments to review and discuss cases regularly.
* The Kowloon East Cluster (KEC) will introduce the "Crew Resource Management" training by end of 2014 to enhance quality.
* The hospital management will strengthen the incident reporting mechanism to ensure the efficiency information management when incidents are reported in future.
The spokesperson said that with reference to the investigation report, UCH will commence human resources proceedings in accordance with prevailing HA policy. UCH also again expresses its deepest apologies to all patients affected and has already offered all necessary examination and treatment to the 17 patients requiring clinical management plan adjustment. UCH will continue to follow the conditions of all patients affected. UCH would like to express heartfelt appreciation to the chairman and members of the panel for their efforts during the investigation.
Ends/Wednesday, October 8, 2014
Issued at HKT 18:58
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