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"HA Risk Alert" latest issue published

The following is issued on behalf of the Hospital Authority:

     The 37th issue of "HA Risk Alert" was published today (April 24) 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 this issue, the HA Chief Manager (Patient Safety and Risk Management), Dr Rebecca Lam, said that the most common types of sentinel events in 2013/14 were "retained instruments or other material after surgery".

     "In view of rapid technological advances in medical care, the surgical instruments used are increasingly complex. The HA recognises that the healthcare staff have focused on the counting of instruments or other material used in the surgery, but have overlooked the completeness of them," Dr Lam said. "The HA has alerted healthcare staff to the need to inspect instruments for completeness after surgery, and has compiled and updated regularly a list of broken instruments/material associated with sentinel events on the website."

     In the last quarter of 2014, there were nine sentinel events reported, including six cases of retained consumables and instruments, two cases of wrong side procedure and a case of patient suicide. Subsequent to root cause analysis, recommendations have been made and shared in this publication to avoid the recurrence of similar events in future.

     During the reporting period there were 17 reported serious untoward events, comprising 13 medication incidents and four cases of patient misidentification. Among the medication incidents, nine cases of overlooking known drug allergy were analysed by their frequency of occurrence in various drug types.

     The publication has been distributed to all health care professionals in public hospitals for continuous quality improvement purposes. 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 is scheduled to be published on July 31.

Ends/Friday, April 24, 2015
Issued at HKT 17:30


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