The following is issued on behalf of the Hospital Authority:
The Hospital Authority (HA) today (January 28) published both the latest quarterly issue of "HA Risk Alert" and the Annual Report on Sentinel and Serious Untoward Events 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 HA spokesperson said the latest issue of "HA Risk Alert" reported one case of retained instrument or material after surgery/interventional procedure and two cases of inpatient suicide. Furthermore, among the 14 reported serious untoward events, there were 12 medication errors and two cases of patient misidentification.
"Subsequent to incident review and analysis of root causes of these incidents, important lessons for patient safety are identified, while recommendations are made and shared in this publication to avoid similar events in future," the spokesperson added.
The HA also released the Annual Report on Sentinel and Serious Untoward Events covering the 12 months from October 1, 2019, to September 30, 2020, after it was discussed and endorsed by the HA Board this afternoon. There were a total of 24 sentinel events reported in the year.
During the year, 50 serious untoward events were also reported, with 45 and five events related to medication error and patient misidentification respectively. Serious untoward events are unexpected occurrences which had not caused death or permanent harm to patients but would have had the potential to do so if there was not timely intervention.
The Annual Report on Sentinel and Serious Untoward Events can be accessed by healthcare workers and the public at www.ha.org.hk/report/sentinel_event, while "HA Risk Alert" has been distributed to the healthcare professionals in public hospitals for continuous quality improvement purposes and can be accessed by the public at www.ha.org.hk/riskalert. The next issue of "HA Risk Alert" will be published on April 30.
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