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HA releases risk management publications
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The following is issued on behalf of the Hospital Authority:

     The Hospital Authority (HA) today (January 25) published both the latest quarterly issue of "HA Risk Alert" and the Annual Report on Sentinel and Serious Untoward Events as a risk management and communication initiative to further strengthen the incident reporting and sharing of lessons learnt for safety improvements in public hospitals.
 
     The HA spokesperson said the latest issue of "HA Risk Alert" reports on four cases of wrong side procedure, four cases of retained instrument or material after surgery/interventional procedure, three cases of patient suicide, an incident of intravascular gas embolism and a case of infant abduction. Furthermore, among the 21 reported Serious Untoward Events, there were 20 medication errors and a case of patient misidentification.
 
     "Subsequent to incident review and analysis of root causes of these incidents, important lessons on patient safety have been identified, while recommendations are made and shared in this publication to avoid similar events in future," the spokesperson added.
 
     The HA also released the Annual Report on Sentinel and Serious Untoward Events covering the 12 months from October 1, 2016, to September 30, 2017, after it was discussed and endorsed by the HA Board this afternoon. In this year's report, there are a total of 40 Sentinel Events reported, as compared to 32 in the last reporting period.
 
     During the year, 69 Serious Untoward Events were also reported, with 61 and eight events related to medication error and patient misidentification respectively. Serious Untoward Events are unexpected occurrences which did not cause death or permanent harm to patients but had the potential to do so without timely intervention. 
 
     The Annual Report on Sentinel and Serious Untoward Events can be accessed by healthcare workers and the public at www.ha.org.hk/report/sentinel_event, while "HA Risk Alert" has been distributed to healthcare professionals in public hospitals for continuous quality improvement purposes and can be accessed by the public at www.ha.org.hk/riskalert. The next issue will be published on April 27.
 
 
Ends/Thursday, January 25, 2018
Issued at HKT 16:54
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