LCQ6: Medical incidents in public hospitals
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Question:
The Hospital Authority (HA) has adopted a sentinel event reporting mechanism since 2007 and added two types of serious untoward events to the mechanism since 2010. Under the mechanism, public hospitals must report such events to the HA Head Office within 24 hours. On the other hand, when two doctors in the Renal Specialist Outpatient Clinic of the United Christian Hospital (UCH) provided high-dose steroid treatments to a hepatitis B (HBV) carrier in January and February this year respectively, they did not concurrently prescribe antiviral prophylaxis to reduce the risk of acute hepatitis flare-up triggered by steroid treatments. Subsequently, the patient suffered from acute hepatitis and underwent two liver transplant surgeries. UCH had all along not reported the event since uncovering this serious untoward event on the 6th of last month, and it did so only after the patient's family made enquiries on the 19th of last month. UCH then made public the event on the 9th of this month. In addition, it has been reported that such nephrologists are not authorised to prescribe hepatology drugs, and they have to refer such cases to the relevant specialists or more senior doctors for decision. In this connection, will the Government inform this Council if it knows:
(1) the number of cases, in each year since HA's adoption of the sentinel event reporting mechanism, in which public hospitals failed to comply with the requirements of reporting such events within 24 hours and details of such cases (including the names of the hospitals involved and whether the staff members involved in delayed reporting on such events were punished); whether HA will conduct an investigation to see if there were events in the past 10 years which have so far not been reported but should have been reported as required, and announce the investigation outcome; if HA will, of the details; if not, the reasons for that;
(2) whether HA will conduct a comprehensive investigation to ascertain whether there were cases, other than the aforesaid UCH incident, in the past 10 years in various public hospitals in which patients were not prescribed anti-HBV prophylaxis despite medical needs and subsequently suffered from acute hepatitis; if HA will, of the details; if not, the reasons for that; and
(3) whether HA will review and relax the restrictions currently imposed on specialists' prescribing drugs of other specialties so as to avoid delays in treatment for patients; if so, of the details; if not, the reasons for that?
Reply:
President,
The Food and Health Bureau (FHB) and the Hospital Authority (HA) are highly concerned about the event mentioned in the question. An independent root cause analysis panel has been set up by the United Christian Hospital (UCH) to investigate the hospital's clinical management of the patient and its communication with the patient and her family, as well as to make recommendations on improvement measures to prevent any recurrence. Apart from the investigation into this event, the HA has also established an independent review panel to conduct a comprehensive review of the current Sentinel and Serious Untoward Event Policy (the Policy), which covers examination of the definition and scope of sentinel and serious untoward events related to clinical incidents, reporting mechanism, as well as notification and announcement mechanisms. The review panel will make recommendations to the HA on follow-up actions according to the findings.
Both panels have commenced their work. The root cause analysis panel is expected to complete its work in mid-June, while the one reviewing the Policy will submit its report to HA Board in early July. The FHB and the HA are closely monitoring the progress of the panels and, with reference to the findings, will formulate improvement measures to ensure implementation and compliance of the Policy, with particular emphasis on the timeliness of notification and announcement.
My reply to the various parts of the question is as follows:
(1) Since the implementation of the Policy by the HA in 2007, about 80% of cases were reported within 24 hours. The remaining cases could not be reported within 24 hours mainly because they were more complicated that the hospitals and clusters concerned might need more time to gather information from the staff members, patients and their family members and to maintain close liaison with relevant departments before determining the nature and category of the events and reporting the cases.
As for cases which are not reported within the time specified, HA Head Office will seek explanation from the clusters and hospitals concerned and conduct reviews to ensure that all hospitals and clusters report the cases to HA Head Office via the Advanced Incident Reporting System (AIRS) within 24 hours and handle the cases in accordance with the established procedures.
In case of any medical incidents, the hospitals concerned should report the incidents, including those outside the scope of specified sentinel and serious untoward events to be reported, to HA Head Office via the AIRS. The hospitals and clusters concerned and HA Head Office will take appropriate actions, such as conducting investigation and reviews, having regard to the nature of the incidents. Where necessary, the HA will appoint an expert panel to conduct detailed analysis with a view to identifying the possible causes of the incidents, and exploring and formulating improvement measures.
By implementing the Policy, the HA intends to encourage its staff to report sentinel and serious untoward events in a timely and open manner to facilitate early investigation so that lessons can be learnt from the events to prevent the recurrence of similar incidents in the future. Hence, instead of releasing the number of sentinel and serious untoward events of individual hospitals, the HA announces the overall figures of all hospitals through its "Risk Alert" and the Annual Report on Sentinel and Serious Untoward Events.
As I have mentioned above, the HA has nevertheless established an independent review panel to conduct a comprehensive review of the Policy, which covers examination on the definition and scope of the events related to clinical incidents, reporting mechanism as well as notification and announcement mechanisms. The review panel will make recommendations to the HA on follow-up actions according to the findings.
(2) In the past 10 years, HA Head Office received a total of three reported cases related to medical incidents in which patients were not prescribed anti-HBV prophylaxis and subsequently suffered from acute hepatitis. The first two cases were investigated and analysed by the respective root cause analysis panels, and later published in the HA's "Risk Alert". The third case is under investigation.
(3) With the advancement of medical technologies, new drugs come into the market from time to time. These drugs are proven to vary in safety, efficacy and cost-effectiveness, as well as their side effects and health outcome. The HA Drug Formulary (HADF) was put in place with a view to ensuring equitable access by patients to cost-effective drugs of proven safety and efficacy through standardisation of policies on drugs and drug utilisation in public hospitals and clinics. In the HADF, general drugs are those with well-established indications and effectiveness available for general use as indicated by relevant clinical conditions, while special drugs are those used under specific clinical conditions with specific specialist authorisation to ensure the safety and efficacy of the drugs used by different specialties.
The HA currently sets out guidelines on the clinical specialties recommended for drug prescription for each type of special drugs as well as the clinical indications of the drugs. The Cluster or the Hospital Drug and Therapeutics Committees may include additional clinical specialties internally for drug prescription for operational needs. Specialists other than those recommended clinical specialties may also prescribe special drugs according to the clinical needs of individual patients upon consultation with the latter. The HA reviews, on a regular basis, the HADF, the clinical indications of various drugs and the clinical specialties recommended for drug prescription, to ensure that its clinical services and drug utilisation can keep up with the latest development of medical technology and scientific evidence. The HA also reviews the prevailing procedures in accordance with the established mechanism to facilitate prescription of special drugs by the specialists concerned.
Ends/Wednesday, May 31, 2017
Issued at HKT 16:12
Issued at HKT 16:12
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