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"HA Risk Alert" latest issue published

The following is issued on behalf of the Hospital Authority:

     The 29th issue of ¡§HA Risk Alert¡¨ is published today (April 26) by the Hospital Authority (HA) as a risk management and communication initiative to further strengthen the reporting and monitoring of medical incidents in public hospitals.

     In the foreword of the latest issue, HA New Territories East Cluster Service Director (Quality & Safety), Dr So Hing-yu, shares his observations on the need to further improve the reporting culture. At the same time, staff training and the reporting system will need to be enhanced. Dr So added that hospitals must ensure the good use of investigation reports, as well as improve root cause analysis, report writing and implementation of improvement actions.

     The reported sentinel events analysed in this issue includes two cases of wrong side procedure, two cases of retained consumables and instrument, and two cases of retained gauze. The issue also highlights the key learning points in five patient suicide cases in the reporting period. Among the 25 reported serious untoward events, there were 22 medication incidents and three cases of patient misidentification. Subsequent to root cause analyses, recommendations are made and shared in this publication to avoid similar events in future.

     This issue also shares information on the risks associated with cold storage devices and tips on managing, handling and maintaining the devices to assure the quality storage of precious materials such as blood components, stem cells, drugs and vaccines.

     The publication also presented the top reported categories of incidents in the Advance Incident Reporting System in the last two quarters of 2012.

     The publication has been distributed to all health care professionals in public hospitals for the purpose of continuous quality improvement. It can also be accessed by the public at

     "HA Risk Alert" is published on a quarterly basis and posted on the HA website every last working Friday in the month of January, April, July and October. The next issue will be published on July 26, 2013.

Ends/Friday, April 26, 2013
Issued at HKT 16:37


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