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HA "Risk Alert" 10th issue published

The following is issued on behalf of the Hospital Authority:

     The 10th issue of ˇ§HA Risk Alertˇ¨ is published today (May 29) by the Hospital Authority as a risk management and communication initiative to further strengthen the reporting and monitoring of adverse incidents in public hospitals.

     Cluster Chief Executive of New Territories East Cluster Dr Fung Hong, pointed out in the foreword of this issue, ˇ§apart from in-hospital suicide, adverse incidents related to surgery and intervention therapy are surprisingly common ˇV due to retained surgical items and wrong side/ site surgery or intervention.ˇ¨  

     He reminded staff to make reference to the World Health Organisation Surgical Safety Checklist which has proved to be effective in decreasing complications from surgery.  

     He remarked that it was time to implement an effective checking system across the Hospital Authority ˇV such as ˇ§Time Outˇ¨ process to ensure verification of key information and process.

     The latest issue of ˇ§HA Risk Alertˇ¨ features a sentinel event of unnecessary procedure of laparoscopic cholecystectomy.  Three other cases of surgical or intervention procedures on the wrong sites are also featured. Subsequent to in-depth root cause analyses during incident investigation, recommendations are made and shared in this publication to avoid similar events in future.

     Common pitfalls in local and overseas healthcare setting are also highlighted to enhance staff vigilance.  Locally, healthcare professionals are reminded to note the risk of wrong infusion rate involving paediatric patients and some possible risk reduction measures.

     The publication has been distributed to all health care professionals in public hospitals for continuous quality improvement purpose.  It can also be accessed by the public on (

     The ˇ§HA Risk Alertˇ¨ is regularly published and posted on the Hospital Authority Internet website every last working Friday in the alternate (odd) month.  The next issue will be published on July 31.

Ends/Friday, May 29, 2009
Issued at HKT 17:16


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