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The following is issued on behalf of the Hospital Authority:
The Hospital Authority today (August 17) announced an enhanced risk management and communication initiative to further strengthen the reporting and monitoring of adverse incidents classified as sentinel events in public hospitals.
"The new system ensures immediate and appropriate management of the event to minimise the harm to the patient, support the staff and minimise the impact of the incident," authority Chairman Mr Anthony Wu said.
The new system is being built on the well-established online reporting system, Advanced Incident Reporting System (AIRS), which was fully implemented across all authority hospitals since March, 2006.
"It is of equal importance that the new system will work to prevent a recurrence of similar incident by conducting a thorough investigation and to share the learning points across the authority," the authority's Director of Quality and Safety, Dr Leung Pak-yin, said.
Public hospitals will be required to report to the Hospital Authority Head Office via the online system the following nine types of sentinel events within 24 hours:
1. Surgery/interventional procedure involving the wrong patient or body part.
2. Retained instruments or other material after surgery/interventional procedure requiring re-operation or further surgical procedure.
3. Haemolytic blood transfusion reaction resulting from ABO incompatibility.
4. Medication error resulting in major permanent loss of function or death of a patient.
5. Intravascular gas embolism resulting in death or neurological damage.
6. Death of an in-patient from suicide (including home leave).
7. Maternal death or serious morbidity associated with labor or delivery.
8. Infant discharged to wrong family or infant abduction.
9. Unexpected death or serious disability reasonably believed to be preventable (not related to the natural course of the individual's illness or underlying condition). Assessment should be based on clinical judgment, circumstances and context of the incident.
"The hospital involved will also need to set up an investigation team within 48 hours and conduct a root cause analysis to be completed within six weeks. The entire investigation should be completed within eight weeks with the final report submitted to the HAHO Quality and Risk Management Division," Dr Leung said.
"The authority will continue to adopt and promulgate the
'just culture' principles to create a safe and supportive environment for staff to report and respond to any future incidents," authority Chief Executive Mr Shane Solomon said.
"We will collate and release to all staff and other concerned healthcare professionals the sentinel events report, without naming staff, patients and hospitals, every six months for experience sharing. The same report will be submitted to the authority board and released to the public," he said.
The new reporting system will be promulgated to the seven hospital clusters next month (September) for the system to be in full implementation in October.
Ends/Friday, August 17, 2007
Issued at HKT 15:46
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