Replies to LegCo questions
LCQ6: Medical incidents in public hospitals
Following is a question by the Dr Hon Helena Wong and a reply by the Secretary
for Food and Health, Dr Ko Wing-man, in the Legislative Council today (May 31):
Question:
The Hospital Authority (HA) has adopted a sentinel event reporting mechanism
since 2007 and added two types of serious untoward events to the mechanism since
2010. Under the mechanism, public hospitals must report such events to the HA
Head Office within 24 hours. On the other hand, when two doctors in the Renal
Specialist Outpatient Clinic of the United Christian Hospital (UCH) provided
high-dose steroid treatments to a hepatitis B (HBV) carrier in January and
February this year respectively, they did not concurrently prescribe antiviral
prophylaxis to reduce the risk of acute hepatitis flare-up triggered by steroid
treatments. Subsequently, the patient suffered from acute hepatitis and
underwent two liver transplant surgeries. UCH had all along not reported the
event since uncovering this serious untoward event on the 6th of last month, and
it did so only after the patient's family made enquiries on the 19th of last
month. UCH then made public the event on the 9th of this month. In addition, it
has been reported that such nephrologists are not authorised to prescribe
hepatology drugs, and they have to refer such cases to the relevant specialists
or more senior doctors for decision. In this connection, will the Government
inform this Council if it knows:
(1) the number of cases, in each year since HA's adoption of the sentinel event
reporting mechanism, in which public hospitals failed to comply with the
requirements of reporting such events within 24 hours and details of such cases
(including the names of the hospitals involved and whether the staff members
involved in delayed reporting on such events were punished); whether HA will
conduct an investigation to see if there were events in the past 10 years which
have so far not been reported but should have been reported as required, and
announce the investigation outcome; if HA will, of the details; if not, the
reasons for that;
(2) whether HA will conduct a comprehensive investigation to ascertain whether
there were cases, other than the aforesaid UCH incident, in the past 10 years in
various public hospitals in which patients were not prescribed anti-HBV
prophylaxis despite medical needs and subsequently suffered from acute
hepatitis; if HA will, of the details; if not, the reasons for that; and
(3) whether HA will review and relax the restrictions currently imposed on
specialists' prescribing drugs of other specialties so as to avoid delays in
treatment for patients; if so, of the details; if not, the reasons for that?
Reply:
President,
The Food and Health Bureau (FHB) and the Hospital Authority (HA) are highly
concerned about the event mentioned in the question. An independent root cause
analysis panel has been set up by the United Christian Hospital (UCH) to
investigate the hospital's clinical management of the patient and its
communication with the patient and her family, as well as to make
recommendations on improvement measures to prevent any recurrence. Apart from
the investigation into this event, the HA has also established an independent
review panel to conduct a comprehensive review of the current Sentinel and
Serious Untoward Event Policy (the Policy), which covers examination of the
definition and scope of sentinel and serious untoward events related to clinical
incidents, reporting mechanism, as well as notification and announcement
mechanisms. The review panel will make recommendations to the HA on follow-up
actions according to the findings.
Both panels have commenced their work. The root cause analysis panel is expected
to complete its work in mid-June, while the one reviewing the Policy will submit
its report to HA Board in early July. The FHB and the HA are closely monitoring
the progress of the panels and, with reference to the findings, will formulate
improvement measures to ensure implementation and compliance of the Policy, with
particular emphasis on the timeliness of notification and announcement.
My reply to the various parts of the question is as follows:
(1) Since the implementation of the Policy by the HA in 2007, about 80% of cases
were reported within 24 hours. The remaining cases could not be reported within
24 hours mainly because they were more complicated that the hospitals and
clusters concerned might need more time to gather information from the staff
members, patients and their family members and to maintain close liaison with
relevant departments before determining the nature and category of the events
and reporting the cases.
As for cases which are not reported within the time specified, HA Head Office
will seek explanation from the clusters and hospitals concerned and conduct
reviews to ensure that all hospitals and clusters report the cases to HA Head
Office via the Advanced Incident Reporting System (AIRS) within 24 hours and
handle the cases in accordance with the established procedures.
In case of any medical incidents, the hospitals concerned should report the
incidents, including those outside the scope of specified sentinel and serious
untoward events to be reported, to HA Head Office via the AIRS. The hospitals
and clusters concerned and HA Head Office will take appropriate actions, such as
conducting investigation and reviews, having regard to the nature of the
incidents. Where necessary, the HA will appoint an expert panel to conduct
detailed analysis with a view to identifying the possible causes of the
incidents, and exploring and formulating improvement measures.
By implementing the Policy, the HA intends to encourage its staff to report
sentinel and serious untoward events in a timely and open manner to facilitate
early investigation so that lessons can be learnt from the events to prevent the
recurrence of similar incidents in the future. Hence, instead of releasing the
number of sentinel and serious untoward events of individual hospitals, the HA
announces the overall figures of all hospitals through its "Risk Alert" and the
Annual Report on Sentinel and Serious Untoward Events.
As I have mentioned above, the HA has nevertheless established an independent
review panel to conduct a comprehensive review of the Policy, which covers
examination on the definition and scope of the events related to clinical
incidents, reporting mechanism as well as notification and announcement
mechanisms. The review panel will make recommendations to the HA on follow-up
actions according to the findings.
(2) In the past 10 years, HA Head Office received a total of three reported
cases related to medical incidents in which patients were not prescribed
anti-HBV prophylaxis and subsequently suffered from acute hepatitis. The first
two cases were investigated and analysed by the respective root cause analysis
panels, and later published in the HA's "Risk Alert". The third case is under
investigation.
(3) With the advancement of medical technologies, new drugs come into the market
from time to time. These drugs are proven to vary in safety, efficacy and
cost-effectiveness, as well as their side effects and health outcome. The HA
Drug Formulary (HADF) was put in place with a view to ensuring equitable access
by patients to cost-effective drugs of proven safety and efficacy through
standardisation of policies on drugs and drug utilisation in public hospitals
and clinics. In the HADF, general drugs are those with well-established
indications and effectiveness available for general use as indicated by relevant
clinical conditions, while special drugs are those used under specific clinical
conditions with specific specialist authorisation to ensure the safety and
efficacy of the drugs used by different specialties.
The HA currently sets out guidelines on the clinical specialties recommended for
drug prescription for each type of special drugs as well as the clinical
indications of the drugs. The Cluster or the Hospital Drug and Therapeutics
Committees may include additional clinical specialties internally for drug
prescription for operational needs. Specialists other than those recommended
clinical specialties may also prescribe special drugs according to the clinical
needs of individual patients upon consultation with the latter. The HA reviews,
on a regular basis, the HADF, the clinical indications of various drugs and the
clinical specialties recommended for drug prescription, to ensure that its
clinical services and drug utilisation can keep up with the latest development
of medical technology and scientific evidence. The HA also reviews the
prevailing procedures in accordance with the established mechanism to facilitate
prescription of special drugs by the specialists concerned.
Ends/Wednesday, May 31, 2017
Issued at HKT 16:12
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