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North District Hospital announces missing specimen incident
The following is issued on behalf of the Hospital Authority:

     The spokesperson for North District Hospital (NDH) made the following announcement today (September 20) regarding a missing specimen incident:

     A female patient, aged 59, with a left breast complex sclerosing lesion with Atypical Ductal Hyperplasia, received a left breast lumpectomy operation in NDH on September 15. A specimen was collected for removal for pathology and formulation of a subsequent diagnostic and treatment plan.

     According to the medical record, the left breast lumpectomy was performed by the case surgeon on September 15 at around 5pm. The specimen, with a diameter of around 3cm, was put into a specimen bag and sent to the Radiology Department for radiological confirmation. It was then sent back to the operation theatre immediately after confirmation.

     At around 7pm, a nurse from the operation theatre received the specimen and transferred the specimen to a formalin-prefilled specimen bottle. She sealed and labelled the bottle before leaving it in a specimen trolley in the operation theatre, which would then be sent to the Pathology Department the next day morning.

     The specimen bottle was transferred from the operation theatre to the Pathology Department on September 16 at around 9am and was placed in cold storage. Since the relevant laboratory service is not open during weekends, the specimen was stored till September 18 (Monday) for histology examination.  

     On September 18 at around 9am, a staff member of the Pathology Department removed the specimen bottle from the cold storage to prepare for the histology examination. However, an assistant Medical Technologist, when cross-checking the specimen, discovered that the specimen bottle only contained formalin and the specimen was found missing. The staff reported the case to the supervisor and relevant departments. An immediate search was conducted throughout the relevant departments but the specimen could not be found.

     The hospital management is very concerned about the incident and reported the it to the Hospital Authority Head Office via the Advance Incident Reporting System on the same day that the specimen was found missing. The surgical team met the patient concerned to explain the incident and express an apology. The team also discussed the follow-up care plan with the patient, including the arrangements for various types of checks and examinations for diagnosis. The team will closely follow up the patient's condition and render the required assistance.

     After preliminary investigation by the hospital, it seemed there were no obvious procedural errors contributing to the loss of the specimen and it might be due to other possible factors. The hospital therefore decided to seek the assistance of the Police yesterday (September 19) and will co-operate with the Police investigation. Furthermore, NDH has taken immediate measures to enhance security for storing specimens in the operation theatre and also to review the process of storing and transferring specimens to prevent recurrence of similar incidents.
Ends/Wednesday, September 20, 2017
Issued at HKT 19:02
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