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The following is issued on behalf of the Hospital Authority:
The Hospital Authority today (August 24) released the "Report on a Medication Incident of Intrathecal Administration of Vincristine in Prince of Wales Hospital" by the Special Investigation Panel commissioned by the Chief Executive of the authority.
Authority Chief Executive Mr Shane Solomon thanked panel members, especially Professor Ian Tannock of Princess Margaret Hospital in Canada and Professor Grace Tang, President of Hong Kong Academy of Medicine, for their efforts and valuable contributions in the investigation which help enhance the quality and safety of patient service.
Chairman of the investigation panel Professor Ian Tannock said the panel has completed investigation into the circumstances surrounding the medication incident and made recommendations to enhance the systems in place in the hospital and the authority to minimise the possibility of human error.
"While the panel recognised that there were guidelines in place to support the safe administration of intravenous and intrathecal chemotherapy in Prince of Wales Hospital and that no similar cases had been reported in any public hospitals, we are of the view that the causes of this unfortunate incident are multiple, and can be broadly separated into three components - system factors, education factors and human error," Professor Tannock said.
Professor Grace Tang elaborated on the recommendations made in the report to prevent a recurrence of the incident, "To improve the system of administration of chemotherapy, the panel recommends that standard operating procedures, based on international guidelines, should be established in all public hospitals which administer intrathecal chemotherapy," she said. "Such procedures will specify, among others, trained and designated staff for administering chemotherapy, formal checking procedure, special containers for transportation and storage of intrathecal drugs, labelling of and physical arrangements in administering such drugs."
"The investigation panel considers that medication incidents are less likely to occur if all clinical staff are educated to recognise the potential hazards in the use of anti-cancer therapy," Professor Tang said.
To improve the education of staff, the panel recommended that the training programme of medical oncologists should be modified in line with international trends to allow protected time from clinical duties for structured training and rotations when trainees can concentrate on particular types of malignancies.
"In addition, regular in-service education should be provided for pharmacists and nurses working in the oncology field," Professor Tang said.
Mr Solomon said the report pointed to a mix of system and education factors, combined with human error.
"On the system and education side, we plan to have the panel's recommendations implemented at all our hospitals providing cancer service. These will introduce system and process changes to reduce the chance of human error."
Mr Solomon said the Hospital Authority would form an investigation panel chaired by the Head of Human Resources to meet and interview the staff concerned and make recommendations to him.
"As professional staff, I know we will all learn from this unfortunate event and work towards a safer and better hospital environment for our patients," Mr Solomon said.
The "Report on a Medication Incident of Intrathecal Administration of Vincristine in Prince of Wales Hospital" is now available at the HA Homepage www.ha.org.hk/investigation_panel/pwh/report_eng.pdf.
Ends/Friday, August 24, 2007
Issued at HKT 18:56
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