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Thursday, 22 January 2015
HA Releases Publications on Risk Management
The latest quarterly issue of “HA Risk Alert” is published today (22 January)
by the Hospital Authority (HA) 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 current issue of “HA Risk Alert” reported three cases of retained
consumables and instruments, two cases of medication incident and an incident
of misplaced nasogastric feeding tube. The reported events also included five
cases of patient suicide. Among the reported serious untoward events, there
were 21 medication incidents and a case 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.
Furthermore, HA also released the Annual Report on Sentinel and Serious
Untoward Events covering the 12 months from 1 October 2013 to 30 September
2014, which was discussed and endorsed by the HA Board today.
In this year’s report, there were a total of 49 sentinel events reported during
the period, as compared with 26 cases in last year report.
Serious untoward events are unexpected occurrence which had not caused
death or permanent harm to patients but would have the potential to do so if not
intervened timely. During the year, 94 serious untoward events have been
reported, with 85 and nine events related to medication error and patient
misidentification respectively.
The Annual Report on Sentinel and Serious Untoward Events can be
accessed
by
health
care
workers
and
the
public
at
http://www.ha.org.hk/report/sentinel_event, while the “HA Risk Alert” has been
distributed to the healthcare professionals in public hospitals for continuous
quality improvement purpose and can be accessed by the public at
http://www.ha.org.hk/riskalert. The next issue will be published on 24 April
2015.
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