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Tuen Mun Hospital announces incident related to preparation of operating theatre equipment

The following is issued on behalf of the Hospital Authority:

     The spokesperson of Tuen Mun Hospital (TMH) today (August 12) announced the following incident related to preparation of operating theatre equipment:

     On June 3 this year, a female patient underwent oral surgery at TMH. As part of the procedure, the operating theatre staff dipped a bronchoscope used by her into a bottle of sterile water and drew out a small amount of it which was immediately discarded after flushing through the bronchoscope.

     The same operating theatre was then used by a male patient who also underwent oral surgery. The theatre staff did not follow the standing procedures to replace the used sterile water. Instead, the leftover sterile water was used to prepare for the softening of the endotracheal tube which was used during the operation.

     Sterile water is micro-organism-free processed water. It is commonly used for the preparation of operating theatre equipment.

     After reviewing the medical records and clinical conditions of the two patients, doctors in charge of the operations came to the conclusion that as the first female patient does not carry any known risk of infectious diseases, the risk for the male patient being cross-infected would be extremely low. The medical team has been following up with the male patient and he is in stable condition, so the operating theatre staff only managed this incident within the department. No report was made to the hospital management via the Advance Incident Reporting System.

     The hospital management, informed of the incident last week on August 4, has formed an investigation panel to follow up on the incident and reported it to the Hospital Authority Head Office.

     TMH is highly concerned about this incident. The two patients concerned were contacted yesterday and blood tests were immediately arranged to ascertain if there is any infection. The hospital expressed sincere apologies to the patients and will continue to provide them with appropriate treatment and support. The hospital management has also reviewed the procedures of preparation of operating theatre equipment and reminded health-care staff to be prudent. They are also reminded to follow the guidelines accordingly and report any medical incidents in a timely manner in order to avoid a similar incident happening again.

Ends/Tuesday, August 12, 2014
Issued at HKT 18:29


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