Hospital Authority sets up Root Cause Analysis Panel to enhance effectiveness of X-ray findings assessment
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The Hospital Authority (HA) today (November 21) announced the establishment of a Root Cause Analysis (RCA) Panel following three cases of undue oversight of abnormal X-ray findings that happened recently.
The HA noted three incidents of undue oversight of abnormal X-ray findings reported by hospitals via the Advance Incident Reporting System recently. Due to the coincidence in reporting time and similarities in the nature of the incidents, the Quality and Safety Department decided to set up an RCA Panel at the Head Office level to collectively examine the three cases with a view to exploring means to better support healthcare workers and ensure that they can identify abnormalities in chest X-ray findings in a more timely manner.
In consideration of patients' and families' wishes of masking their individual particulars, below is the salient information of the cases concerned.
1) A patient was admitted to the surgical ward of Prince of Wales Hospital via the Accident and Emergency Department (AED) for cholecystitis in November this year. Chest X-ray examination was arranged and an opacity over the left upper zone of the lung was found. Upon reviewing the patient's previous chest X-ray films, the doctor noted that the patient had taken an X-ray examination at the hospital in March 2017 and the X-ray film also showed a shadow on the left lung. Computed tomography (CT) scanning of the thorax, the abdomen and the pelvis was then arranged and the report showed a left upper lobe lung mass highly suspected to be malignant. Further investigations confirmed that the patient has a metastatic lung tumour. The patient is receiving appropriate medical treatment as indicated.
2) A patient of Queen Mary Hospital (QMH) sought medical treatment at Ruttonjee Hospital in October this year due to epigastric discomfort. A chest X-ray was performed and the report showed a mass suspected to be malignant. The patient was referred to Grantham Hospital for further assessment from the Tuberculosis and Chest Medicine Unit. Upon reviewing the patient record, it was found that among the chest X-rays taken in QMH since 2016, the mass had not been detected three times. The hospital has now arranged follow-up examinations for the patient to establish the most suitable treatment plan.
3) A patient attended the AED of Princess Margaret Hospital in November this year due to a fall accident. The patient was suffering from dyspnea and was admitted to the Medicine and Geriatrics ward. Chest X-ray examination suggested massive pleural effusion and therefore a chest drain procedure was arranged to deal with the condition. A subsequent pleural fluid cytology finding confirmed that the patient has lung cancer. Upon reviewing patient's chest X-ray films taken in February 2017 and May 2018, it was found that a shadow in the right lung was unnoticed on both occasions. The patient is now being taken care of by the Medicine and Geriatrics Department as well as the Oncology Department. CT scanning has been arranged for further examination and devising a treatment plan.
Open disclosure has been conducted by the three hospitals concerned in addition to expressing apologies to the patients and their families. The three hospitals will continue to provide follow-up treatment according to the patients' clinical conditions and to provide assistance as necessary to the patients and their families. The hospitals have reminded front-line colleagues to be cautious in reviewing patients' examination findings to ensure timely diagnosis and treatment.
The HA attaches great importance to the quality and safety of patient services and has grave concern over the irregularities. The HA will invite representatives from Central Co-ordinating Committees of respective specialties to participate in the RCA Panel. The report will be completed and disclosed in eight weeks.
Ends/Wednesday, November 21, 2018
Issued at HKT 18:08
Issued at HKT 18:08
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