Hospital Authority announces follow-up actions for two sentinel events
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The spokesperson of the Hospital Authority (HA) made the following announcement today (July 6) regarding two sentinel events and immediate follow-up actions:
The Hospital Authority Head Office (HAHO) has recently received reports from Queen Elizabeth Hospital (QEH) on two cases of retained metal stylet in patient's body. The HAHO Quality and Safety Division reviewed the preliminary information of the incidents and today issued a safety alert to remind all clusters to be alert and evaluate the practice in using the product. There is no other report of similar incidents at the moment.
QEH is very concerned about safety of both patients and medical products, and would contact the manufacturer for further information. The QEH introduced this new model of implantable long-dwelling catheter last year, which can be inserted into a patient's body for continuous and repeated infusion of drugs. The inner metal stylet for supporting the catheter should be removed after the insertion of the catheter.
A cancer patient underwent surgical procedures at QEH in 2016 and 2017 for inserting catheters, through the left side and right side of the neck respectively, into the superior vena cava for chemotherapy. The hospital's routine review of the patient's chest X-ray images revealed that a segment of metal stylet was retained in the patient's right heart region after removal of the catheter. The metal stylet, inside the catheter inserted subsequently into the patient's superior vena cava through the left neck, was not removed.
QEH reviewed the X-ray images of five other patients who had used the same model of catheter, and confirmed that another cancer patient also had a retained metal stylet inside the catheter. QEH has reported the two cases to the HAHO via Advance Incident Reporting System.
The QEH has arranged the two patients for check-up and removed their catheters. They have been discharged from hospital. The treatment outcomes of the two patients' chemotherapy were not affected. The situation was openly disclosed to the patients and their families. The QEH will set up a Root Cause Analysis Panel to investigate into the incidents and the report is to be submitted to HAHO in eight weeks. The relevant investigation findings would also be shared in the quarterly issue of "HA Risk Alert".
Ends/Thursday, July 6, 2017
Issued at HKT 21:30
Issued at HKT 21:30
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