Replies to LegCo questions
LCQ17: Practice and procedures in handling medical incidents
Following is a question by the Hon James To and a written reply by the Secretary
for Food and Health, Dr Ko Wing-man, in the Legislative Council today (November
5):
Question:
In September this year, medical incidents occurred in Tseung Kwan O Hospital and
Haven of Hope Hospital respectively in which healthcare personnel mistakenly
inserted a feeding tube into a patient's lung and infused excessive amount of
drugs into another patient's body. Thereafter, the patients passed away. I have
also received requests for assistance from patients' family members regarding
medical incidents. They suspect that some healthcare personnel made wrongful
diagnoses due to negligence and some patients even died as a result. These
family members indicated that the successive occurrence of medical incidents in
public hospitals has made them worry about the quality of public medical
services, and they gave up pursuing their cases because they encountered
numerous obstacles in the course of tracking down the responsible party for
medical blunders. As a result, their interests have been undermined and they
have lost confidence in the public healthcare system. In this connection, will
the Government inform this Council whether it knows:
(1) the respective numbers of sentinel events and serious untoward events that
occurred in public hospitals in each of the past five years, with a breakdown by
name of hospital and type of sentinel events requiring reporting to the
Department of Health; the respective numbers of cases among these events
involving mistakes made by nursing staff and doctors;
(2) if the Hospital Authority (HA) has assessed the effectiveness of
implementing the patient safety round programme and using two-dimensional
barcode and radiofrequency for patient identification in reducing medical
incidents; if HA has, of the findings;
(3) given that HA staff informed a relevant Panel of the Legislative Council in
November 2009 that it would set up a central Staff Discipline Committee to
advise the Cluster Chief Executives on disciplinary actions for sentinel events,
and would establish a central mechanism to review such incidents, of the current
arrangement and progress of the relevant work;
(4) the types of disciplinary actions taken by HA against the healthcare
personnel proved to have made mistakes; the respective numbers of times for
which various disciplinary actions were taken by HA in each of the past five
years; if HA has examined whether the existing span of disciplinary actions is
adequate; if HA has, of the details; if not, the reasons for that;
(5) if the Medical Council of Hong Kong will take the initiative to investigate
the medical incidents that occurred in public hospitals; and
(6) if HA has long-term plans to enhance the quality of medical services in
public hospitals; if HA does, of the details?
Reply:
President,
The Hospital Authority (HA) has attached great importance to service quality and
patient safety. It has put in place mechanisms and guidelines to conduct
clinical audits and deal with medical incidents. My reply to the various parts
of the question is as follows:
(1) HA has implemented a policy on the reporting of sentinel events since
October 2007 to standardise the practice and procedures in handling sentinel
events in all hospital clusters, mandating hospitals to report nine types of
"sentinel events"(Note 1). Subsequently in January 2010, HA improved the
reporting mechanism and required hospitals to report two additional types of
"serious untoward events" (Note 2). Under the policy, hospitals/clusters should
report sentinel and serious untoward events within 24 hours through the Advance
Incident Reporting System. They should also handle the incidents properly in
accordance with the established procedures so as to minimise any possible harm
of the events to patients and at the same time provide support to the staff
involved. The hospitals concerned will investigate the causes of the events and
submit reports to HA Head Office.
The number of sentinel and serious untoward events reported to HA Head Office in
the past five years are set out by type in Annex 1 and Annex 2.
The provision of healthcare service requires the collaboration among healthcare
professionals of different disciplines and the support of advanced technologies.
With the advancement of medical technology, treatment procedures have become
more sophisticated. The emergence of complications, side-effects of drugs and
changes in patients' conditions may also increase the risks involved in
treatment procedures. The causes of medical incidents are multifaceted, with
system and procedural factors, rather than human issues, as the main causes. The
aim of HA's sentinel event policy is to enable healthcare professionals to learn
from and share experiences on the incidents, so as to enhance safety and quality
of service and achieve the long-term objective of continuous service quality
improvement.
HA will conduct a detailed analysis on each sentinel and serious untoward event
with a view to identifying the possible cause of the incident and formulating
improvement measures to avoid recurrence of a similar incident. Each year, HA
Head Office will submit to HA Board a report of sentinel events, which will also
be released to the public. Internally, HA facilitate the healthcare
professionals to share among themselves the experience of handling medical
incidents through staff training and the quarterly "Risk Alert" newsletter.
(2) HA has implemented various initiatives to enhance patient safety and service
quality, including patient safety rounds. Senior management of HA Head Office,
hospitals and clusters will lead the patient safety rounds and listen to the
frontline staff on their suggestions and concerns regarding protocols and
procedures in their daily work settings which concern patient safety. The aim is
to encourage the frontline staff to provide feedback to the management to
identifying patient safety issues, formulating improvement measures and
simplifying work process.
Regarding the use of 2D barcode, the 2D barcode system has been adopted for all
blood and microbiological tests in HA hospitals. The phase 3 Unique Patient
Identification (UPI) project for specimens collection has also been completed.
HA will continue to explore the adoption of 2D barcode system in different
areas, such as mobile X-ray examination in Accident & Emergency Departments and
wards, so as to enhance patient identification and reduce human errors. Since
the introduction of reporting serious untoward event in January 2010, there has
only been one case of patient misidentification related to sample mislabeling,
which occurred at a clinical department that had not adopted the 2D barcode
system.
In addition, HA has introduced Radio Frequency Identification (RFID) and UPI to
eliminate possible errors on the identification of dead bodies. The installation
of RFID system has been completed in 12 mortuaries and is underway in six other
mortuaries. There has been no incident relating to the misidentification of dead
bodies in public hospitals since 2007.
(3) HA has put in place an established mechanism to handle disciplinary matters
of its staff, including those arising from medical incidents. The relevant
procedures of the disciplinary actions are laid down in the Human Resources
Policies Manual so that hospital clusters can adopt a consistent approach to
handle disciplinary matters. Based on real cases happened in various clusters,
the central human resources department has also set up a Disciplinary Cases
Inventory for reference by human resources departments of clusters in handling
disciplinary cases. Since HA has already had an established disciplinary
mechanism in place, it, after careful consideration, has not set up a central
Staff Discipline Committee to handle disciplinary actions arising from sentinel
events.
(4) HA has an established and proper arrangement for disciplinary actions. It
will consider appropriate disciplinary actions according to different factors of
individual cases. Types of disciplinary actions include verbal warning, written
warning, stoppage of increment, deferment of increment, dismissal etc. The
number of disciplinary actions taken in the past five years are as follows:
Year Number of disciplinary actions
2009/10 296
2010/11 267
2011/12 324
2012/13 302
2013/14 363
(5) Upon receiving information or complaints about the professional conduct of
registered medical practitioners, the Medical Council of Hong Kong (MCHK) will
handle the case according to the Medical Registration Ordinance and its
subsidiary legislation, i.e. Medical Practitioners (Registration and
Disciplinary Procedure) Regulation (Cap.161 E).
When MCHK investigates into medical incidents that occurred in public hospital,
HA will provide assistance to facilitate the investigation as far as possible.
(6) HA has all along been making every effort to enhance the quality of medical
service in public hospitals. With the policy steering and support of the
Government, HA launched the Pilot Scheme of Hospital Accreditation in 2009. The
objective of the scheme is to assess and improve hospital service through an
independent accrediting agent which adopts a set of internationally recognised
framework of standards. The participating hospitals have to conduct
self-assessment on their performance in accordance with international standards
every year. Afterwards, the accrediting team will conduct survey at the
hospitals and make suggestions on improvement. After taking follow-up actions
and making improvements, the hospitals have to report to the accrediting team,
so as to ensure that their services can meet international standards and the
quality of the services can keep improving.
HA has also set up a communication and electronic platform in order to
facilitate the sharing and follow-up of the suggestions of the accrediting teams
and improvement measures. In the past few years, HA has co-ordinated improvement
suggestions which involved substantial input of resources and wide implications
on hospital operation, in order to promote the overall enhancement of HA. For
example, on clinical aspects, HA has conducted a comprehensive review on the
sterilising facilities in operating theatres since 2011/12. A broad variety of
improvement programmes have been implemented in hospitals by stages, including
the replacement and addition of sterilising facilities in operating theatres,
acquisition of additional surgical instruments and endoscopes, development of
the surgical equipment tracking system, enhancement of staff training, etc.
In order to equip healthcare personnel with proper clinical skills and improve
patient safety, HA is actively preparing for the development of credentialing
and defining scope of practice. The central committee concerned will continue to
discuss and collaborate with stakeholders to decide on the medical procedures
which require qualification accreditation and the relevant professional
standards.
Note 1:
The nine types of "sentinel events" required to be reported are:
(a) Surgery/interventional procedure involving the wrong patient or body part;
(b) Retained instruments or other material after surgery/interventional
procedure;
(c) ABO incompatibility blood transfusion;
(d) Medication error resulting in major permanent loss of function or death;
(e) Intravascular gas embolism resulting in death or neurological damage;
(f) Death of an in-patient from suicide (including home leave);
(g) Maternal death or serious morbidity associated with labour or delivery;
(h) Infant discharged to wrong family or infant abduction; and
(i) Other adverse events resulting in permanent loss of function or death
(excluding complications).
Note 2:
The two types of "serious untoward events" required to be reported are:
(a) Medication error which could led to death or permanent harm; and
(b) Patient misidentification.
Ends/Wednesday, November 5, 2014
Issued at HKT 17:27
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LCQ17 Annex 1
LCQ17 Annex 2