North District Hospital announces a serious untoward event
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The spokesperson for the North District Hospital made the following announcement today (September 1) regarding a serious untoward event:
A 64-year old male patient was admitted into the medical ward of the hospital via the Accident and Emergency Department (AED) for abdominal pain, vomiting and weakness in the lower limbs on April 23. He was diagnosed with diabetes mellitus and cardio-vascular disease. On April 24, computed tomography scan confirmed that he had pancreatic cancer which had metastasized to the liver. After having undergone a period of treatment and observation, he was discharged in the morning of May 4 with discharge medications which contained drugs for diabetes mellitus, heart conditions and blood pressure. While the patient was waiting for discharge, the ward nurse put the drugs in the drawer for discharged patients' drugs and had not handed them to the patient when he left the ward. The patient was eventually discharged from the hospital that afternoon via Non-Emergency Ambulance Transfer Services.
According to patient's relative, she went to the ward on May 8 to enquire if the patient had been prescribed with discharge medications and was told no medications had been prescribed on his discharge. In the morning of May 17, ward staff discovered a drug package inside the drug drawer. After checking it was found that it belonged to the above discharged patient. His relative was contacted to get back the drugs from the hospital. Unfortunately the patient was found unconscious at home in the afternoon on the same day. He was sent to the AED of the hospital by ambulance and was certified dead after failing resuscitation. The case was reported to the Coroner. According to the death report, the cause of his death is cancer of pancreas with metastasis.
On August 28, the hospital received feedback from the patient's relative that the patient had not been given discharge medications. It was noted that the incident had not been reported to the hospital management.
The hospital is highly concerned about the incident. An expert panel will be set up to conduct an in-depth investigation into the incident and to review the workflows with regard to the handling of discharge medications, relatives' enquiries and reporting of incidents and to make recommendations on improvement. Meanwhile, the incident has been reported to the Hospital Authority Head Office via the Advance Incident Reporting System.
As regard the handling of discharged patients' drugs, drug prescriptions will be printed on patients' discharge summaries and ward staff are required to check if the discharge medications have been delivered to ward. There are also notices to remind staff to retrieve the discharge medications from the designated drug drawer. The electronic Patient Record (ePR) system is available in all wards, allowing staff to check up patients' medication records and to answer related enquiries, and incidents relating to medication are to be reported to the ward management.
Subsequent to the incident, the hospital has implemented the following measures to further enhance clinical governance, with a view to prevent similar incidents from happening again:
1. All wards have arranged designated staff to check the designated drawer for discharge medications daily to ensure that all medications have been given out to the patients discharged that day;
2. All staff members are reminded again to strictly follow the established workflow in checking and handling discharge medications;
3. Ward staff are required to document enquiries from discharged patients or their relatives regarding drug prescriptions or sudden change in patients' health conditions so that other members of the team are aware of the enquiries and can follow up accordingly; and
4. Frontline staff training on incident reporting would be enhanced.
The hospital is deeply saddened by this unfortunate incident and would like to extend its sincere apology and condolences to the deceased's relatives. The Patient Relations Office will keep close communication with the relatives to update them of the investigation results in a timely manner and will provide them with any assistance as far as feasible.
Ends/Saturday, September 1, 2018
Issued at HKT 18:27
Issued at HKT 18:27
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