Replies to LegCo questions

LCQ2: Medical incidents

Following is a question by the Hon Wong Yuk-man and a written reply by the Secretary for Food and Health, Dr York Chow, in the Legislative Council today (March 28):

Question:

Medical incidents occur in public hospitals one after another in recent years, resulting in the partial loss of functional capacity of quite a number of patients and even the loss of lives. The hospitals did not make announcement to the public and the media on the incidents on many occasions on the ground that such incidents were not among the types of events required to be reported under the Hospital Authority's (HA) sentinel and serious untoward events policy ("types of reportable events"). For instance, it was reported in February this year by the media that a doctor at Prince of Wales Hospital used a ventouse to extract a baby in the course of delivery in September last year, and the baby was later confirmed to have a cerebral haemorrhage, but the hospital denied that this was a medical incident and did not give an account of the incident to the public. In this connection, will the Government inform this Council whether it knows:

(a) if HA has any plan to revise the "types of reportable events" at present; if not, the reasons for that; and

(b) given that HA currently requires public hospitals to report all sentinel and serious untoward events to the HA Head Office within 24 hours, what measures HA has in place to ensure that the hospitals under it comply with the requirements of such reporting mechanism?

Reply:

President,

(a) and (b) One of the characteristics of healthcare services is that the provision of services always involves collaboration among healthcare professionals of different disciplines and support of advanced technologies. With the innovation and advancement of medical technologies, treatment procedures have become more complex, and the risks involved have also increased. The change of a patient's conditions and the efficacy of treatment can be affected by a number of factors, including the emergence and development of symptoms, whether patient's condition is stable, whether the patient is suffering from other diseases, as well as the known risks of the treatment procedures, side-effects of drugs and emergence of complications, etc. Take colonoscopy as an example. In the unfortunate event that the intestinal wall is pierced, it is necessary to conduct a detailed analysis to find out whether it is caused by known risks, complications, clinical conditions of the patient or human factors. Since not all treatment procedures can achieve 100% of their intended medical outcome, healthcare professionals will explain to the patient and his/her family members in detail the treatment procedures involved, including the known risks and possible complications, etc. before the treatment is carried out.

On reporting and handling of medical incidents, the Hospital Authority (HA) has since 2004 introduced an electronic Advanced Incidents Reporting System (AIRS), to enable frontline staff to report incidents directly, thereby facilitating the hospitals concerned to take prompt actions to support the staff and patients involved. HA subsequently implemented a Sentinel Event Policy in October 2007 with reference to international practice, to standardise the process for reporting, investigation and management of these medical incidents in public hospitals, and to require hospitals to report the nine categories of sentinel events listed in the Annex. In January 2010, HA further improved the reporting mechanism by mandating the reporting of two more categories of serious untoward events, namely, medication error and misidentification of patient that could have led to death or permanent harm.

Under HA's Sentinel and Serious Untoward Event Policy, the hospital concerned is required to report to the HA Head Office all sentinel and serious untoward events within 24 hours and immediately handle the incidents properly so as to minimise any possible harm caused to patients, their family members and the staff involved and provide them with the necessary support. For cases with immediate major impact on the public or involving patients' death, HA will consider disclosing the events with a proper account of the events to the public.

At the same time, HA will carry out a detailed analysis on each sentinel event and serious untoward event with a view to identifying the likely cause of the incident and formulating improvement measures to avoid recurrence of a similar incident. Each year, the HA Head Office will submit to the HA Board a report on sentinel events, which will also be released to the public. Internally, through staff training and the three-monthly "Risk Alert" newsletter, HA shares among the healthcare professionals the experience of handling medical incidents. In addition, through the Chiefs of Service and teams of clinical departments, HA will from time to time review the work and clinical competency of other doctors, in order to maintain professional standards.

HA understands that good and effective clinical governance is the foundation for provision of quality healthcare services. Through professional accountability, HA has always endeavoured to ensure the professional standards of its healthcare staff and continued improvement of its service quality, so as to enhance patient safety and reduce the risks of medical incidents. The existing policy and reporting mechanism of medical incidents of HA is comparable to those of other advanced countries and regions. The transparency of HA's relevant mechanism and integrity of HA's healthcare workers are widely recognised by international experts. Nevertheless, HA will continue to review its clinical governance system with reference to international standards.


Ends/Wednesday, March 28, 2012
Issued at HKT 16:27

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Annex to LegCo Q2