Queen Mary Hospital accepts investigation report on intra-operative break
The spokesperson for Queen Mary Hospital (QMH) today (January 5) announced the findings and recommendations of the investigation report regarding the surgical arrangement of a liver transplant operation, and accepted the panel's conclusions and recommendations.
QMH received a staff report on October 18, 2017, about an intra-operative break during a liver transplant surgery operation on October 13. The hospital was very concerned about the incident. An investigation panel was set up and the report was submitted to Hospital Chief Executive of QMH in late December.
"After interviewing the related medical staff members and reviewing relevant documents, the investigation panel confirmed that the there was an unnecessary and avoidable intra-operative break of three hours during the operation, while the case was an isolated incident," the spokesperson said.
The investigation panel opined that Honorary Consultant of QMH's Department of Surgery, Dr Ng Kwok-chai, did not make an alternative arrangement to avoid the potential clash between his on-call duty and an elective surgery arranged in a private hospital. He also made a wrong judgement that Honorary Associate Consultant of QMH's Department of Surgery, Dr Tiffany Wong, could complete the operation alone, and did not discuss with Dr Wong in advance about any contingency arrangement.
The panel noted that Dr Wong decided to seek support from senior doctors to supervise the surgery after assessing the graft's condition. With due consideration, she decided not to complete the operation alone.
The anesthesia of the recipient and ischemic time of the graft had been prolonged for three hours by the break. The patient has recovered and been discharged. The panel, however, considered this intra-operative break not in the best interest of the patient. The panel also found it unacceptable for Dr Ng not to make any alternative arrangement for the operation to proceed and to avoid unnecessary delay.
The panel also examined the manpower and call arrangement of the liver transplant team. It was noted that the manpower situation was similar to previous years and there was no similar incident happening before. The panel concluded that the manpower or call arrangement were irrelevant to the occurrence of the incident, the spokesperson added.
The panel noted that the role of supervisor surgeons was mostly taken up by Dr Ng and an associate professor. In the past year, Dr Ng had performed and supervised the largest number of transplant operations.
The panel has made the following recommendations to QMH to prevent the future occurrence of such an incident:
1. Setting up a code of conduct for enhancement of communication and contingency measures inside the operating theatre
2. On appointing honorary medical staff, the hospital should issue the code of practice to regulate the roles and responsibilities, and specifically emphasise that that if the doctor is put on the call list, he/she should make timely response to attend to the needs of patients
3. Promote the Crew Resources Management concept to the Liver Transplantation Division and the staff working in the operating theatre so as to improve the timeliness and accuracy of communication
4. The Department of Surgery is recommended to review the job assignment of liver transplant surgeons in the Hepatobiliary and Pancreatic Surgery Division and Liver Transplantation Division with a view to optimising the use of each surgeon's expertise and, at the same time, avoid the potential "burn out" of individual surgeons.
The spokesperson said that QMH has accepted the recommendations of the investigation panel. "The hospital is highly concerned about patient safety. QMH will follow up the case seriously in accordance with the established human resources policy. The hospital also expresses its gratitude to the investigation panel."
Membership of the panel is as follows:
Dr Tong Hon-kuan
Deputy Hospital Chief Executive, Queen Mary Hospital
Mr Joseph Lo
Member of Queen Mary Hospital's Hospital Governing Committee
Professor Stephen Cheng
Head of Department of Surgery, University of Hong Kong/
Chief of Service, Department of Surgery, Queen Mary Hospital
Professor Joseph Lui
Clinical Director of University of Hong Kong Health System
Ends/Friday, January 5, 2018
Issued at HKT 16:20
Issued at HKT 16:20