*******************************************************
The following is issued on behalf of the Hospital Authority:
The spokesperson of Pamela Youde Nethersole Eastern Hospital (PYNEH) made the following announcement today (October 30) regarding the investigation report on a sentinel event:
PYNEH announced a sentinel event on August 26, 2015, and thereafter appointed a panel, with participation of independent members, radiology experts and pathology experts, to investigate the root cause of the incident and to make recommendations for improvement. The panel has completed the investigation and the report has been submitted to the Hospital Authority Head Office and PYNEH.
A 64-year-old male patient with a lung nodule was arranged for a CT-guided lung biopsy at PYNEH for diagnosis and treatment planning. The biopsy investigation result indicated malignancy of the lung nodule and the patient was referred to Queen Mary Hospital (QMH) for lobectomy of the right lower lobe. The pathological investigation of the patient's excised lung tissue confirmed the clinical diagnosis was pulmonary tuberculosis. DNA fingerprinting studies proved that the specimen taken was found to contain tissue of another patient with confirmed lung cancer. The discrepancy in diagnoses had resulted in the patient receiving an unnecessary operation to remove part of the lung. The hospital had a meeting with the patient and family members on August 26 to explain the incident in detail, and expressed apologies. The incident was announced to the public on the same day.
The panel has interviewed the staff concerned, examined the workflows and reviewed the relevant documents, qualification of staff involved and manpower status on the day of the incident. The panel has concluded that three factors are believed to have contributed to the contamination of the specimen, including biopsy collection, tissue wrapping and embedding in the laboratory. A comprehensive review for improvement has been conducted.
The panel has made the following recommendations to the hospital:
* To ensure a specimen bottle will not be used once the seal is broken or removed, to eliminate the additional use of rinsing bottles for biopsy procedures, to label a specimen bottle once it's designated to a patient and to enhance the documentation of specimen nature and quantity;
* To stagger the sequence of handling specimens of similar nature whenever possible and to facilitate the ease of single use of forceps in tissue wrapping and embedding; and
* To ensure adequate checking and traceability in laboratories, including a double-checking mechanism for tissue wrapping and ensuring traceability in the entire specimen processing, in particular tissue wrapping and embedding procedures.
PYNEH would implement the recommendations to prevent similar incidents from happening again and would take other follow-up actions as and when necessary. The hospital has met the patient concerned to explain the report findings and expressed again sincere apologies to him. The hospital will continue to follow up on his clinical condition. PYNEH also expresses appreciation to the chairman and members of the panel. Membership of the panel is as follows:
Chairman
--------
Professor To Ka-fai
Honorary Chief of Service (Anatomical and Cellular Pathology)
Prince of Wales Hospital
Members
-------
Dr Wong Yiu-chung
Chief of Service (Radiology and Nuclear Medicine)
Tuen Mun Hospital and Pok Oi Hospital
Dr Tang Chung-ngai
Deputy Hospital Chief Executive and Chief of Service (Surgery)
Pamela Youde Nethersole Eastern Hospital
Ms Chiang Yim-ha
Advanced Practice Nurse (Imaging and Interventional Radiology)
Prince of Wales Hospital
Mr Wong Wing-ming
Department Manager (Pathology)
Tseung Kwan O Hospital
Dr Rebecca Lam Kit-yi
Chief Manager (Patient Safety and Risk Management)
Hospital Authority Head Office
Ends/Friday, October 30, 2015
Issued at HKT 18:42
NNNN
