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The following is issued on behalf of the Hospital Authority:
Members of the Hospital Authority (HA) Board were briefed at the Board Meeting today (September 21) on the new initiatives proposed by the management to further enhance patient safety and public accountability.
HA Chairman Mr Anthony Wu stressed that, while health care settings are complex and inherently risky, the Authority has the prime responsibility to safeguard patient's safety. ¡§It is important that, through effective incident management, frontline staff can share and learn the experience while opportunities are taken to improve systems and processes.¡¨
Mr Wu also reiterated the approach of open disclosure in handling medical incident.
¡§Open disclosure of incidents to patient and family must be implemented in all public hospitals. With the consent of family and patient, serious cases will also be disclosed to the public in a timely manner.¡¨
The HA currently publishes all sentinel events in the bimonthly publication HA Risk Alert as well as the biannual progress reports.
Chief Executive Mr Shane Solomon said HA and hospital risk management teams have implemented a lot of quality initiatives in the past few years on prevention of top health care risks such as patient misidentification, fall and pressure sore in patients and Methicillin Resistant Staphylococcus Aureus (MRSA) infection.
¡§We are delighted to see that hospitals have made notable improvements in these areas, which are comparable with our overseas counterparts,¡¨ he said.
In response to public concern towards several recent hospital incidents, HA has submitted to the Food & Health Bureau improvement plans in several key areas to enhance patient safety.
Mr Solomon said that the proposed improvement include the introduction of a new system for incident management; peer review and patient feedback system; enhancement in pharmacy safety; use of technology to reduce human error; to address staff workload issue and to reform human resources policy and process.
Under the new system for incident management, HA will extend the mandatory reporting criteria for incident which has a risk of leading to serious harm to patients, even if there is no actual harm done.
A core team will also be established in the HA Head Office (HAHO) to review these sentinel incidents so as to ensure consistency. ¡§This will also help balance between independent review and hospital responsibility,¡¨ he added.
¡§The core team will comprise senior clinicians, nurses and allied health staff from all hospital clusters. In addition, lay members from Hospital Governing Committees will also be invited as members of the core team to enhance the transparency of the incident review process.¡¨
There will be a similar mix of professional and lay members, within and across hospital clusters in the setup of the four- to five-member Root Cause Analysis Panel established to conduct investigations of each sentinel event.
The second area of improvement is on Peer Review and Patient Feedback System.
¡§Patient Safety Round will be conducted to review practice and simplify protocols of various processes, inter alia, patient admission and discharge, clinical handover, infection control, medication management, and patient consent,¡¨ added Mr Solomon.
¡§To further improve the collection of public feedback, we will soon conduct a patient satisfaction survey and revamp the current complaints system.¡¨
¡§Advanced technology such as 2D barcode will also be adopted more extensively to reduce human errors such as patient misidentification and mix up of blood specimen,¡¨ Mr Solomon added that other identification technology, for example, radiofrequency identification in babies and bodies will also be explored.
He concurred that the management is fully aware that frontline colleagues are working under immense pressure with the current manpower and patient load. A dedicated taskforce has already been addressing the issues of doctor work hours and workload.
¡§The reopening of nursing schools also cast a more promising outlook in nursing manpower. The number of nurses graduated each year will grow from 700 per year last year to 1,800 in 2012. Our nursing managers will be working on a new set of nurse workload standard, as well as allocating extra nurses under training to the heaviest workload area.¡¨
While every effort will be made by the management to facilitate frontline staff to deliver their duties safely, efficiently and effectively, some human errors may still inadvertently occur with different degree of responsibility.
As Root Cause Analysis helps define the causes of errors, including system and human factors, the actual disciplinary action has been decided by hospital management according to existing human resources policies.
¡§To address staff and public concern about the due process and consistency in disciplinary actions among different hospital clusters and hospitals, the existing human resources policy will be reviewed.¡¨
In addition, a central mechanism for reviewing all cases retrospectively will be set up to share lessons learned and best practice. There will also be a ¡§Consistency Checklist¡¨ against which line management can check the nature and severity of issues against the options of discipline. They can also access dedicated advisors from Cluster and HAHO Human Resources to see advice on precedents.
For very serious clinical incident, cases will be reviewed by a central Staff Disciplinary Committee.
¡§Certainly, our ultimate goal is to eliminate clinical incidents as far as possible. But if an unfortunate incident still happens despite proper safety systems and effective guidelines, the public would expect us to demonstrate accountability by implementing appropriate disciplinary actions on those making mistakes. For our colleagues, we will ensure that these actions are determined under HA¡¦s just culture,¡¨ Mr Solomon concluded.
Ends/Monday, September 21, 2009
Issued at HKT 19:50
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