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The following is issued on behalf of the Hospital Authority:
The Hospital Authority (HA) Board at its meeting today (January 28) discussed and endorsed the Annual Report on Sentinel Events covering the 12 months from October 1, 2008, to September 30, 2009.
Members noted that the HA Sentinel Event Policy was introduced in October 2007 to further strengthen the reporting, management and monitoring of serious medical incidents in public hospitals. The first annual report was published in January 2009.
In this year's report, there were 40 sentinel events reported during the period, down from the 44 events in the first annual report. It was noted that the drop was mainly due to the reduction in reported suicide cases, which has all along topped all categories of reported events.
HA Chief Executive Mr Shane Solomon pointed out that in the course of investigating the sentinel events, the Root Cause Analysis conducted had identified contributing factors for inpatient suicide, retained instruments or material, surgery/interventional procedures involving wrong patient or body part and maternal death.
As a result, various risk reduction programmes have been implemented across HA to enhance patient safety, including:
- Implementation of Safe Surgery Policy on June 1, 2009;
- Extension of the use of two-dimensional barcode for patient identification;
- Prevention of inpatient suicide through enhanced patient risk assessment for suicide and reduction of environmental risk.
Mr Solomon said that HA had also implemented a revised "Sentinel and Serious Untoward Event Policy" since January 1 this year to further strengthen the reporting and prevention of serious adverse events which could have led to serious permanent harm or death.
HA today published two regular bulletins to promote risk management among healthcare professionals in public hospitals - the "HA Risk Alert" and the "Medication Incident Reporting Programme" (MIRP) Bulletin.
Important lessons of patient safety identified from the root cause analysis during incident investigation will be collated and shared among healthcare professionals in the bi-monthly publication "HA Risk Alert".
The latest issue of "HA Risk Alert" featured a number of cases of retained intravascular guidewire or gauze material in patients during surgical or interventional procedures and several cases of wrong level spinal surgery. Subsequent to in-depth root cause analyses of incident investigation, recommendations are made and shared in this publication to avoid similar events in future.
With a particular focus on medication issues, the MIRP was first established in 1994 as a continuous quality improvement initiative through regular case sharing and statistical analysis of reported incidents. In this latest issue, the bulletin highlighted three cases for sharing with recommendations to prevent recurrence of incidents of similar nature. The MIRP bulletin is published every six months.
The Annual Report on Sentinel Events can be accessed by the health care workers and the public at http://www.ha.org.hk/report/sentinel_event, while the two risk management bulletins have been distributed to the healthcare professionals in public hospitals for continuous quality improvement purpose and can be accessed by the public at http://www.ha.org.hk/riskalert and http://www.ha.org.hk/ho/mirp.
Ends/Thursday, January 28, 2010
Issued at HKT 18:48
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