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Prince of Wales Hospital releases Investigation Panel findings on medication incident

The following is issued on behalf of the Hospital Authority:

     The Prince of Wales Hospital today (September 22) released the investigation findings regarding a drug prescription incident on July 9, 2011, involving a 73-year-old female patient. The Investigation Panel has found that insufficient communication between the duty resident doctor and the house officer, and the fact that the house officer had not checked the patient's identity, led to duplicated prescriptions, which caused the patient's condition to deteriorate. The patient subsequently died. The Hospital expresses its deep condolences and apologies to the patient's family. The Hospital will assume responsibility for this unfortunate incident and will keep close contact with the family.

     According to the investigation report, the patient had a history of diabetes mellitus, hypertension, aortic stenosis, heart disease, chronic renal failure and anaemia. She attended the Accident and Emergency Department on the night of July 8 due to shortness of breath and bilateral leg oedema and was transferred to the medical ward early the next morning (July 9). The admission resident doctor assessed the patient and wrote 'resume usual med, stop Zocor, lasix to IV' on the patient's medical notes. The resident transcribed the patient's usual medications, including aspirin, calcium carbonate, Lasix and Pantoloc, directly onto the patient's Medication Administration Record (MAR). He then asked a house officer to follow up on the management.

     The Panel found that the house officer read the notes and perceived the instruction was for her to resume the patient's usual medications in addition to those already prescribed on the MAR. She transcribed the medications listed on a printout from the Electronic Patient Record onto the MAR. The printout actually belonged to another patient admitted earlier. The medications included Candesartan, Gliclazide, Metformin, Betaloc and Isordil.

     The medications were administered to the patient during the morning medication round at around 7.30am. The transcription error was detected during the doctors' round at around 10.30am. The administration instruction was adjusted immediately. The patient was put under close observation. The patient was found hypotensive at around 11am and intravenous inotropic drugs were given. She was transferred to the High Dependency Unit for close monitoring and treatment. Her blood pressure quickly returned to the level on her admission, but she remained in critical condition and passed away two days later.
     The Panel has identified the root causes of the incident as follows:

(1)   Communication breakdown
The admission resident documented his prescription plan and completed the transcription of the medications onto the MAR as well, but the house officer misinterpreted his notes as an instruction, resulting in duplicated transcription unnecessarily.

(2)   Lack of a standard practice in handling printouts from the Electronic Patient Record
The printout belonging to another patient admitted earlier was not properly filed or handled. It was left unattended on the doctors' station and mistaken as belonging to the index patient.

(3)   Non-compliance with the guidelines for checking a patient's identity
The house officer had not checked the patient's identity on the printout before transcribing.

     The Panel made the following recommendations:

(1)   To improve the documentation of patient care by clearly stating what actions have been done and what needs to be done.

(2)   To standardise the handling and filing procedures of printouts from the Electronic Patient Record.

     The Hospital has accepted the report from the Investigation Panel and will follow up on the recommendations. The Hospital has also met the deceased's family to explain the details of the report and expressed its condolences again. The case has been reported to the Coroner. Assistance will be provided to facilitate the Coroner's investigation.

     The Hospital has notified the medical school of the report findings. Follow-up actions will be taken according to established human resources procedures.

     The Hospital is deeply grateful to the Chairman and members of the Investigation Panel for their work in completing the report.

     The Cluster Co-ordinator (Quality and Safety) of New Territories East Cluster, Dr So Hing-yu, served as the Chairman of the Investigation Panel. Other members included:

-   Member, Hospital Governing Committee, Prince of Wales Hospital, Mr Peter Mok;   

-   Co-ordinator (Clinical Services), Prince of Wales Hospital, Dr Li Chi-kong;

-   Consultant (Medicine), Alice Ho Miu Ling Nethersole Hospital,
Dr Jonas Yeung;

- Representative, Central Co-ordinating Committee (Medicine), Hospital Authority, Dr Law Chun-bong; and

-  Representative, Quality and Safety Division, Hospital Authority, Dr Adrian Tse.

Ends/Thursday, September 22, 2011
Issued at HKT 19:10


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