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Hospital Authority welcomes recommendations of Review Panel on Sentinel and Serious Untoward Event Policy
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The following is issued on behalf of the Hospital Authority:

     The Hospital Authority (HA) has welcomed the recommendations of the Review Panel on Sentinel and Serious Untoward Event Policy. On behalf of the HA Board, the HA Chairman, Professor John Leong, today (July 4) expressed appreciation to the Review Panel members for their effort in conducting a comprehensive review on the current policy following a recent incident in United Christian Hospital (UCH).

     Professor Leong said he was pleased to note the Panel's conclusion that there was a robust governance structure at the HA Head Office (HAHO) and cluster levels to oversee the incident reporting and management issues while significant efforts had been made to continue to improve the mechanism over the years.

     "I would like to thank Professor Maurice Yap and Mr Ricky Fung for the comprehensive review and the valuable input to guide our further enhancement in the Sentinel and Serious Untoward Event Policy implemented 10 years ago," Professor Leong said.

     The HA Chief Executive, Dr Leung Pak-yin, welcomed the recommendations of the Panel and said the HA will continue to be open and accountable by implementing a series of actions accordingly.

     "Timely open disclosure and prompt public disclosure have been the key concerns of the public towards the recent incident at UCH. We will establish corporate policy on open disclosure and enhance the corporate public disclosure framework, including the timing and mode of prompt public disclosure, and the frequency and mode of publishing relevant statistics and risk alerts," Dr Leung said.

     "Definitions of certain Sentinel and Serious Untoward Events will be supplemented with explanatory notes and examples to help front-line staff identify and report these incidents in a timely manner. We will also define a clear line of authority to resolve differences in opinions among clusters, hospitals and the HAHO regarding the classification of an incident."

     The summary of the findings and recommendations of the Review Report is now available on the HA website (www.ha.org.hk/goto/sereviewpanel/en) for public viewing.

     At the same time, the HA also accepted the investigation report on the UCH incident by the Root Cause Analysis (RCA) panel co-chaired by independent clinical expert and Chair Professor of the Department of Medicine of the University of Hong Kong Professor Daniel Chan and the Clinical Stream Coordinator (Medicine) of Kowloon East Cluster, HA, Dr Lau Ip-tim.

     Dr Leung thanked Professor Chan for leading the investigation of the RCA panel, which has made valuable recommendations to the hospital to prevent recurrence of such an incident.

     "Specific recommendations will also be taken forward at the HAHO level for corporate-wide implementation such as exploring measures to highlight the risk related to the administration of high-dose immunosuppressive medications in treatment guidelines and using information technology solutions," Dr Leung remarked.

     On behalf of the HA, Dr Leung apologised again to the UCH patient and her family for the inadvertent omission of the antiviral medication, as well as failing to meet the general public's expectations in the timely management of the incident.
 
Ends/Tuesday, July 4, 2017
Issued at HKT 18:20
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