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LCQ17: Practice and procedures in handling medical incidents
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     Following is a question by the Hon James To and a written reply by the Secretary for Food and Health, Dr Ko Wing-man, in the Legislative Council today (November 5):

Question:

     In September this year, medical incidents occurred in Tseung Kwan O Hospital and Haven of Hope Hospital respectively in which healthcare personnel mistakenly inserted a feeding tube into a patient's lung and infused excessive amount of drugs into another patient's body. Thereafter, the patients passed away. I have also received requests for assistance from patients' family members regarding medical incidents. They suspect that some healthcare personnel made wrongful diagnoses due to negligence and some patients even died as a result. These family members indicated that the successive occurrence of medical incidents in public hospitals has made them worry about the quality of public medical services, and they gave up pursuing their cases because they encountered numerous obstacles in the course of tracking down the responsible party for medical blunders. As a result, their interests have been undermined and they have lost confidence in the public healthcare system. In this connection, will the Government inform this Council whether it knows:

(1) the respective numbers of sentinel events and serious untoward events that occurred in public hospitals in each of the past five years, with a breakdown by name of hospital and type of sentinel events requiring reporting to the Department of Health; the respective numbers of cases among these events involving mistakes made by nursing staff and doctors;

(2) if the Hospital Authority (HA) has assessed the effectiveness of implementing the patient safety round programme and using two-dimensional barcode and radiofrequency for patient identification in reducing medical incidents; if HA has, of the findings;

(3) given that HA staff informed a relevant Panel of the Legislative Council in November 2009 that it would set up a central Staff Discipline Committee to advise the Cluster Chief Executives on disciplinary actions for sentinel events, and would establish a central mechanism to review such incidents, of the current arrangement and progress of the relevant work;  

(4) the types of disciplinary actions taken by HA against the healthcare personnel proved to have made mistakes; the respective numbers of times for which various disciplinary actions were taken by HA in each of the past five years; if HA has examined whether the existing span of disciplinary actions is adequate; if HA has, of the details; if not, the reasons for that;

(5) if the Medical Council of Hong Kong will take the initiative to investigate the medical incidents that occurred in public hospitals; and

(6) if HA has long-term plans to enhance the quality of medical services in public hospitals; if HA does, of the details?
 
Reply:

President,

     The Hospital Authority (HA) has attached great importance to service quality and patient safety. It has put in place mechanisms and guidelines to conduct clinical audits and deal with medical incidents. My reply to the various parts of the question is as follows:

(1) HA has implemented a policy on the reporting of sentinel events since October 2007 to standardise the practice and procedures in handling sentinel events in all hospital clusters, mandating hospitals to report nine types of "sentinel events"(Note 1). Subsequently in January 2010, HA improved the reporting mechanism and required hospitals to report two additional types of "serious untoward events" (Note 2). Under the policy, hospitals/clusters should report sentinel and serious untoward events within 24 hours through the Advance Incident Reporting System. They should also handle the incidents properly in accordance with the established procedures so as to minimise any possible harm of the events to patients and at the same time provide support to the staff involved. The hospitals concerned will investigate the causes of the events and submit reports to HA Head Office.

     The number of sentinel and serious untoward events reported to HA Head Office in the past five years are set out by type in Annex 1 and Annex 2.

     The provision of healthcare service requires the collaboration among healthcare professionals of different disciplines and the support of advanced technologies. With the advancement of medical technology, treatment procedures have become more sophisticated.  The emergence of complications, side-effects of drugs and changes in patients' conditions may also increase the risks involved in treatment procedures. The causes of medical incidents are multifaceted, with system and procedural factors, rather than human issues, as the main causes. The aim of HA's sentinel event policy is to enable healthcare professionals to learn from and share experiences on the incidents, so as to enhance safety and quality of service and achieve the long-term objective of continuous service quality improvement.

     HA will conduct a detailed analysis on each sentinel and serious untoward event with a view to identifying the possible cause of the incident and formulating improvement measures to avoid recurrence of a similar incident.   Each year, HA Head Office will submit to HA Board a report of sentinel events, which will also be released to the public. Internally, HA facilitate the healthcare professionals to share among themselves the experience of handling medical incidents through staff training and the quarterly "Risk Alert" newsletter.

(2) HA has implemented various initiatives to enhance patient safety and service quality, including patient safety rounds. Senior management of HA Head Office, hospitals and clusters will lead the patient safety rounds and listen to the frontline staff on their suggestions and concerns regarding protocols and procedures in their daily work settings which concern patient safety. The aim is to encourage the frontline staff to provide feedback to the management to identifying patient safety issues, formulating improvement measures and simplifying work process.

     Regarding the use of 2D barcode, the 2D barcode system has been adopted for all blood and microbiological tests in HA hospitals. The phase 3 Unique Patient Identification (UPI) project for specimens collection has also been completed. HA will continue to explore the adoption of 2D barcode system in different areas, such as mobile X-ray examination in Accident & Emergency Departments and wards, so as to enhance patient identification and reduce human errors. Since the introduction of reporting serious untoward event in January 2010, there has only been one case of patient misidentification related to sample mislabeling, which occurred at a clinical department that had not adopted the 2D barcode system.

     In addition, HA has introduced Radio Frequency Identification (RFID) and UPI to eliminate possible errors on the identification of dead bodies. The installation of RFID system has been completed in 12 mortuaries and is underway in six other mortuaries. There has been no incident relating to the misidentification of dead bodies in public hospitals since 2007.  

(3) HA has put in place an established mechanism to handle disciplinary matters of its staff, including those arising from medical incidents. The relevant procedures of the disciplinary actions are laid down in the Human Resources Policies Manual so that hospital clusters can adopt a consistent approach to handle disciplinary matters. Based on real cases happened in various clusters, the central human resources department has also set up a Disciplinary Cases Inventory for reference by human resources departments of clusters in handling disciplinary cases. Since HA has already had an established disciplinary mechanism in place, it, after careful consideration, has not set up a central Staff Discipline Committee to handle disciplinary actions arising from sentinel events.

(4) HA has an established and proper arrangement for disciplinary actions. It will consider appropriate disciplinary actions according to different factors of individual cases. Types of disciplinary actions include verbal warning, written warning, stoppage of increment, deferment of increment, dismissal etc. The number of disciplinary actions taken in the past five years are as follows:

  Year     Number of disciplinary actions
2009/10                 296
2010/11                 267
2011/12                 324
2012/13                 302
2013/14                 363

(5) Upon receiving information or complaints about the professional conduct of registered medical practitioners, the Medical Council of Hong Kong (MCHK) will handle the case according to the Medical Registration Ordinance and its subsidiary legislation, i.e. Medical Practitioners (Registration and Disciplinary Procedure) Regulation (Cap.161 E).  

     When MCHK investigates into medical incidents that occurred in public hospital, HA will provide assistance to facilitate the investigation as far as possible.   

(6) HA has all along been making every effort to enhance the quality of medical service in public hospitals. With the policy steering and support of the Government, HA launched the Pilot Scheme of Hospital Accreditation in 2009. The objective of the scheme is to assess and improve hospital service through an independent accrediting agent which adopts a set of internationally recognised framework of standards. The participating hospitals have to conduct self-assessment on their performance in accordance with international standards every year. Afterwards, the accrediting team will conduct survey at the hospitals and make suggestions on improvement. After taking follow-up actions and making improvements, the hospitals have to report to the accrediting team, so as to ensure that their services can meet international standards and the quality of the services can keep improving.

     HA has also set up a communication and electronic platform in order to facilitate the sharing and follow-up of the suggestions of the accrediting teams and improvement measures. In the past few years, HA has co-ordinated improvement suggestions which involved substantial input of resources and wide implications on hospital operation, in order to promote the overall enhancement of HA.  For example, on clinical aspects, HA has conducted a comprehensive review on the sterilising facilities in operating theatres since 2011/12. A broad variety of improvement programmes have been implemented in hospitals by stages, including the replacement and addition of sterilising facilities in operating theatres, acquisition of additional surgical instruments and endoscopes, development of the surgical equipment tracking system, enhancement of staff training, etc.

     In order to equip healthcare personnel with proper clinical skills and improve patient safety, HA is actively preparing for the development of credentialing and defining scope of practice. The central committee concerned will continue to discuss and collaborate with stakeholders to decide on the medical procedures which require qualification accreditation and the relevant professional standards.

Note 1:
The nine types of "sentinel events" required to be reported are:
(a) Surgery/interventional procedure involving the wrong patient or body part;
(b) Retained instruments or other material after surgery/interventional procedure;
(c) ABO incompatibility blood transfusion;
(d) Medication error resulting in major permanent loss of function or death;
(e) Intravascular gas embolism resulting in death or neurological damage;
(f) Death of an in-patient from suicide (including home leave);
(g) Maternal death or serious morbidity associated with labour or delivery;
(h) Infant discharged to wrong family or infant abduction; and
(i) Other adverse events resulting in permanent loss of function or death (excluding complications).

Note 2:
The two types of "serious untoward events" required to be reported are:
(a) Medication error which could led to death or permanent harm; and
(b) Patient misidentification.

Ends/Wednesday, November 5, 2014
Issued at HKT 17:27

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