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The following is issued on behalf of the Hospital Authority:
The Hospital Authority Board discussed at its Administrative and Operational Meeting today (July 30) the Half Year Report on Sentinel Events covering the six months from October 1, 2008, to March 31 this year.
Board members noted that the Hospital Authority Sentinel Event Policy was introduced in October 2007 to further strengthen the reporting, management and monitoring of serious medical incidents in public hospitals. Hospital Authority Chief Executive Mr Shane Solomon said that the entire Hospital Authority would learn from the reported events and to change systems and processes for greater patient safety.
During the reporting period, a total of 25 sentinel events were reported, among which the most common event was patient suicide, which also resulted in 11 cases of patient death.
There were seven events with retained instruments or other material after surgery or interventional procedure which required re-operation or further surgical procedure. Another five cases involved wrong patients or body parts during surgery or interventional procedures. All 12 patients recovered without permanent injury.
There were also two maternal deaths associated with delivery. Both mothers failed to respond to active resuscitation.
¡§Important lessons learned from the reported events have been shared amongst all Hospital Authority staff in the bi-monthly newsletter ¡¥HA Risk Alert¡¦ and appropriate risk reduction strategies are being implemented to reduce the recurrence of similar incidents,¡¨ Mr Solomon said.
The board members also noted a series of improvement activities being undertaken to further enhance patient safety. They include:
- To implement the ¡§Surgical Safety Policy¡¨ to ensure that the correct patient receives the right operation at the correct site and time
- To pilot a training programme with its curriculum based on Crew Resource Management framework, which is proved to be efficacious in aviation industry
- To standardise a suicidal risk scanning tool to identify ¡§at-risk¡¨ patient for appropriate management and support thereby reducing the risk of self-harm and suicidal attempts
- To encourage hospitals to adopt environmental risk scanning for further mitigation of elements or feature that can be used for suicidal acts
- To educate the relatives or care-givers on personal needs of psychiatric patients and empower them to take appropriate measures when patients have changes in mental state during home leave period
The Half Year Report on Sentinel Events can be accessed by health care workers and members of the public on http://www.ha.org.hk/report/sentinel_event.
Ends/Thursday, July 30, 2009
Issued at HKT 19:38
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