Replies to LegCo questions
LCQ17: Medical incident reporting system
Following is a question by the Hon Kwok Ka-ki and a written reply by the
Secretary for Food and Health, Dr York Chow, in the Legislative Council today
(July 9):
Question:
The Hospital Authority (HA) launched the Advanced Incident Reporting System in
2006 and has implemented a Sentinel Event policy since October 2007 to
strengthen the reporting, management and monitoring of sentinel events in public
hospitals. HA also makes public these events in its internal newsletter to alert
frontline medical staff to prevent the recurrence of the events. In this
connection, will the Government inform this Council whether:
(a) it knows what mechanism HA has in place to ensure that frontline medical
staff report medical incidents accurately; and
(b) it will consider requiring, through administrative instructions or even by
legislation, that HA must not disclose the places of the incidents and the names
of the medical staff involved when making public the medical incidents
concerned, so as to encourage medical staff to report such incidents
proactively?
Reply:
Madam President,
(a) The Hospital Authority (HA) has put in place an established mechanism and
guidelines for medical staff to report medical incidents and take follow-up
actions. Under the existing mechanism, hospital clusters will make immediate
reports of medical incident to the HA Head Office through HA's internal Advanced
Incident Report System (AIRS). In addition, HA has since October 2007
implemented a Sentinel Event Policy to strengthen the reporting, management and
monitoring of sentinel events in public hospitals, so as to further enhance
patient safety. Under the above Policy, hospital clusters are required to report
via the AIRS any medical incidents classified as sentinel events within 24 hours
upon awareness of their occurrence. They should at the same time handle the
incident promptly in accordance with the established procedures so as to
minimise the harm caused to the patient and provide support to the staff
involved in the incident. The HA Head Office is responsible for monitoring and
coordinating the handling of sentinel events and implementation of initiatives
for promoting patient safety at an organisational level.
As to follow-up actions on medical incidents, the hospitals concerned will
investigate the causes of the sentinel events and take follow-up actions. They
are also required to submit a report on the event to the HA Head Office. HA will
improve the relevant systems and working procedures where necessary, with a view
to avoiding recurrence of similar incidents in future. Through the training
provided by HA and the internal newsletter "Risk Alert" published by HA, the
staff of different clusters could make reference to and draw on the experience
in handling sentinel events.
(b) As a public body, HA has the responsibility to make public the causes and
details of medical incidents in a transparent and open manner. This would help
HA fosters mutual trust and a respectful relationship with the public. In the
case of serious medical incidents, HA may disclose the places where the incident
took place as well as the grade and rank of the medical staff involved when
making public the details of the medical incidents. However, the identity of the
medical staff will not be disclosed. Under the principle of being accountable to
the public in a transparent and open manner, we consider the practice of not
disclosing the places where medical incidents occurred is not feasible and
preferable. HA will endeavour to maintain the high quality of services and at
the same time promote a learning culture among its staff so as to encourage them
to communicate with patients and their families professionally under the
principle of mutual trust and respect and explain to them the causes and
consequences of medical incidents, to report medical incidents accurately and
reduce the chance of mistake.
Ends/Wednesday, July 9, 2008
Issued at HKT 12:21
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