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The following is issued on behalf of the Hospital Authority:
The 18th issue of "HA Risk Alert" is published today (September 24) by the Hospital Authority (HA) as a risk management and communication initiative to further strengthen the reporting and monitoring of adverse incidents in public hospitals.
In this latest issue, the HA Chief Executive, Shane Solomon, told colleagues that HA's focus on patient safety is on how to change systems to improve the safety of patients. "We also support staff to embrace an open disclosure policy because incident reporting has proved to be a useful tool to learn from the experience of adverse events and near-misses. Senior executives need to create a fair and just culture in order to foster openness and honesty. In HA, we value learning and continuous improvement rather than blame and punishment."
This issue published a sentinel event involving an unnecessary operation on a patient's left calcaneus due to mistaken computer tomography images. After in-depth root cause analysis and investigation of the incident, recommendations are made and shared in this publication to avoid similar events in future.
The distribution of Serious Untoward Events in the first six months of 2010 was also charted by the nature of the events. Serious Untoward Event is an extension of the Sentinel Event Policy to further enhance the reporting and learning culture. A number of Serious Untoward Events involving medication errors were featured to heighten staff awareness of look-alike-sound-alike drugs and to caution on the administration of diabetes mellitus drugs, anti-coagulant agents and dangerous drugs.
Also highlighted for sharing and learning was the good practice in patient identification adopted in an outpatient clinic and some global experience in prevention of retained parts and materials after surgery.
The publication has been distributed to all healthcare professionals in public hospitals for continuous quality improvement. It can also be accessed by the public at www.ha.org.hk/riskalert .
"HA Risk Alert" is regularly published and posted on the HA website every last working Friday in alternating (odd) months. The next issue will be published on November 26.
Ends/Friday, September 24, 2010
Issued at HKT 17:07
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