HA releases risk management publications

The following is issued on behalf of the Hospital Authority:

     The Hospital Authority (HA) today (January 24) published the latest quarterly issue of “HA Risk Alert” and the Annual Report on Sentinel and Serious Untoward Events as a risk management and communication initiative to further strengthen the incident reporting and sharing of lessons learnt for safety improvements in public hospitals.
     The HA spokesperson said the latest issue of "HA Risk Alert" reported one case of retained instrument or material after surgery/interventional procedure, three cases of patient suicide, one case of maternal death and one case of others. Furthermore, among the 24 reported Serious Untoward Events, there were 21 medication errors and three cases of patient misidentification.
     "Subsequent to incident review and analysis of root causes of these incidents, important lessons of patient safety are identified, while recommendations are made and shared in this publication to avoid similar events in future," the spokesperson said.
     Similarly, the HA also released the Annual Report on Sentinel and Serious Untoward Events covering the 12 months from October 1, 2017 to September 30, 2018 after it was discussed and endorsed by the HA Board this afternoon. In this year's report 22 Sentinel Events are reported, as compared to 40 in the last reporting period.
     During the year, 83 Serious Untoward Events were also reported, with 76 related to medication error and seven to patient misidentification.  Serious Untoward Events are unexpected occurrences which did not cause death or permanent harm to patients but would have the potential to do so without timely intervention. 
     The Annual Report on Sentinel and Serious Untoward Events can be accessed by health care workers and the public at www.ha.org.hk/report/sentinel_event, while "HA Risk Alert" has been distributed to healthcare professionals in public hospitals for continuous quality improvement purposes and can be accessed by the public at www.ha.org.hk/riskalert. The next issue will be published on April 26.

Ends/Thursday, January 24, 2019
Issued at HKT 17:06