Tseung Kwan O Hospital announced a delayed investigation incident
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The spokesperson of Tseung Kwan O Hospital (TKOH) today (July 23) announced the following incident regarding a delayed follow-up on a Computerised Tomography investigation report for a patient:
A 68-year-old male patient was admitted to the surgical ward of TKOH via the Accident and Emergency Department (AED) on July 19, 2014 for epigastric pain, fever and septic shock. He was arranged for Computerised Tomography of abdomen and pelvis on July 21 and the results showed ruptured calculus cholecystitis, severe cholangitis and common bile ductal stone. Endoscopic retrograde cholangiopancreatography for drainage and emergency operation for cholecystectomy were performed on the same day. The condition of patient was stable post-operatively and he was discharged on July 31.
On June 28, 2018, the patient was admitted to the medical ward of Pok Oi Hospital (POH) via AED for treatment of anaemia. While reviewing the Computerised Tomography of abdomen and pelvis report performed at TKOH in 2014, the physician at POH noted that a right anterior mediastinal shadow was also reported in addition to the findings of ruptured calculus cholecystitis, severe cholangitis and common bile ductal stone. Since the upper extend of the shadow was not covered in the examination report by TKOH, the radiologist of TKOH during image reporting then suggested a Computerised Tomography of thorax should be further performed for the patient. However, it was noticed that no further investigation on thorax and follow-up had been arranged by the TKOH surgeon as the treatment has been concentrated on cholecystitis.
Upon noticed the situation, the doctor of POH then suggested the patient to undergo a Computerised Tomography scan of thorax. The investigation was conducted and completed on July 6, 2018, and the right anterior mediastinal mass was found increased in size. The patient was then transferred by POH to Tuen Mun Hospital (TMH) medical ward on July 16 for further investigation including biopsy of the concerned lesion for confirmation of pathology and to offer appropriate treatment accordingly. The related condition has also been conveyed to TKOH surgeon.
A meeting with the patient and his relatives was arranged for explaining the incident and discussing the management plan by TKOH doctors with apology and deep condolences extended. The condition of patient is stable and his subsequent follow up and treatment will be managed by TMH, while the Patient Relations Officer will render necessary support to the patient and his relatives.
TKOH has reported the incident to the Hospital Authority Head Office and an investigation will be conducted for reviewing the related workflow and making recommendations. Healthcare professionals have been reminded to stay alert to the investigation results of patients in order to ensure timely documentation and follow-up.
Ends/Monday, July 23, 2018
Issued at HKT 21:22
Issued at HKT 21:22
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