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Queen Elizabeth Hospital announces investigation findings on sentinel event
The following is issued on behalf of the Hospital Authority:

     The spokesperson of Queen Elizabeth Hospital (QEH) today (May 12) announced the findings of the Investigation Panel regarding a sentinel event.

     A 54-year-old woman suffering from severe headache, drowsiness and vomiting attended Accident and Emergency Department of Tseung Kwan O Hospital on the night of March 7 (Tuesday). The patient was diagnosed with severe intracranial hemorrhage and hydrocephalus. She was thus immediately transferred to the QEH Neurosurgery Department for further treatment.

     In the morning on March 8 (Wednesday), the patient underwent a computed tomography (CT) angiogram of brain. The images showed that she had hydrocephalus and aneurysm with bleeding on the right side of the brain, causing an increase in intracranial pressure. As the patient was in a critical and life-threatening condition, an urgent craniotomy had to be arranged for her. The investigation found that the neurosurgeon had promptly arranged an urgent left craniotomy for the patient. The neurosurgeon did not mark the surgical site on the patient’s skull before the operation. During the operation, an anesthetist reviewed the detailed CT angiogram report which was uploaded to the Clinical Management System (CMS) shortly after the operation has commenced. The report indicated the aneurysm was located at the right side of brain. The anesthetist immediately alerted the neurosurgical team. The team then reviewed the findings and rectified the procedures after completing the first phase of an operation to drain the cerebrospinal fluid. The neurosurgeon placed back the bone flap on the left side of the skull, then proceeded to perform a right craniotomy. The patient had been in good progress after the operation, and was discharged after recovery.  

     The hospital reported the incident to Hospital Authority (HA) Head Office via the Advance Incident Reporting System and set up a Root Cause Analysis Panel to investigate into the incident. The panel reckoned the following: 

1. The panel noted that the medical team had arranged radiological investigation for the patient in an emergency setting, and had made a diagnosis and a timely treatment plan;

2. As the patient was in a critical and life-threatening condition, therefore the medical team decided to arrange an urgent craniotomy for the patient before the radiological images were uploaded to the CMS. The neurosurgeon, based on his recollection of preliminary CT angiogram images, mistakenly perceived that the aneurysm was located in patient’s left brain and arranged an urgent left craniotomy for the patient; and

3. The medical team had followed the standard protocols to perform a "time-out" checking before the operation, including checking of patient identity, surgical site and adverse drug reactions, etc.

     The panel has made the following recommendations to QEH and the HA in order to enhance patient safety:

1. Upload source images onto the CMS as soon as possible for pre-operative detailed checking before a detailed CT angiogram report is available;

2. Review and revise the management protocols and checklists for surgical safety, and to include marking of surgical sites and review of radiological images as part of the "time-out" checking;

3. Explore the feasibility to conduct a second "time-out" checking before an operation, including checking of patient identity, surgical site, etc. before the operation; and

4. Reinforce the practice of having surgeons, anaesthetists, nurses to sign on the surgical safety checklist.

     The QEH has explained the investigation results to the patient's family and delivered an apology again. The hospital will continue to provide them with necessary assistance. 

     A QEH spokesman said the hospital had accepted the panel's findings and recommendations, and submitted the investigation report to the HA Head Office. According to the departmental guidelines at the time, doctors have to balance the urgency of the operation while conducting pre-operation checking and marking of surgical site. The hospital would, based on the investigation findings, review the guidelines.

     The hospital has implemented some of the recommendations, including uploading source images of CT angiogram onto the CMS. In addition, the HA would introduce and implement the recommendations at public hospitals.

     The hospital expressed its gratitude to the chairman and members of the root cause analysis panel. Membership of the panel is as follows:

  • Deputizing Service Director (Quality & Safety), Hong Kong East Cluster; Consultant (Neurosurgery), Pamela Youde Nethersole Eastern Hospital, Dr Pang Kai-yuen

  • Service Director (Radiology), Kowloon Central Cluster; Deputy Hospital Chief Executive (Operations), QEH; Chief of Service (Diagnostic Radiology), QEH, Dr Tang Kwok-wing
  • Service Director (Quality & Safety), Kowloon Central Cluster; Honorary Consultant (Intensive Care Unit), QEH, Dr Osburga Pik-kei Chan
  • Chief of Service (Diagnostic Radiology), Princess Margaret Hospital/ Kwai Chung Hospital/ North Lantau Hospital, Dr Johnny Ka-fai Ma
  • Chief of Service (Anaesthesia & Intensive Care), Tuen Mun Hospital /Pok Oi Hospital, Dr Lam Kwok-key
  • Department Operations Manager (Operating Theatre), Tuen Mun Hospital, Ms Ngan Wai-kuen
  • Chief Manager (Patient Safety & Risk Management), Quality & Safety Division, HA Head Office, Dr Sin Ngai-chuen
Ends/Friday, May 12, 2017
Issued at HKT 21:59
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