New measures on medical errors are only a first step

PUBLISHED : Friday, 24 August, 2007, 12:00am
UPDATED : Friday, 24 August, 2007, 12:00am

The public should welcome the first steps taken by the Hospital Authority for hospitals to improve safety and quality of care through reporting, analysing and learning from adverse outcomes and near misses ('Medics given 24 hours to report errors', August 18).

Hong Kong languishes behind the rest of the developed world where hospital incident and near-miss reporting is concerned. This is partly due to an unhealthy persistence of obsolete 'name, shame and blame' attitudes to medical error, but also to government complacency. In Britain, for example, a National Confidential Inquiry into Patient Outcome and Deaths has existed for nearly 20 years. In 2001, the National Patient Safety Agency was established to facilitate the rapid reporting, investigation and correction of error pathways in clinical care.

These agencies exist to identify and respond to systemic deficiencies in complex health care systems, and are complemented by a National Clinical Assessment Service which promotes patient safety by acting in situations where the performance of doctors gives cause for concern. Analogous bodies exist in America, Australia and New Zealand.

The Hong Kong government should establish a health commission and patient-safety agency, which would ideally be independent of the executive and the Hospital Authority, with wide-ranging powers over public and private hospitals.

In the meantime, private hospitals should be required to establish incident reporting systems as a necessary component of their yearly licensing by the Department of Health.

Currently, private hospitals' reporting of deaths, major accidents, important near misses and so-called 'sentinel' events [unexpected occurrences involving death or serious physical or psychological injury] to the department is done voluntarily; the inherent conflict of interest between protecting the public health and limiting institutional liability is obvious.

Nor can the coroner be relied upon to act rapidly. Coroner's inquests often follow more than two years after the event, by which time memories have faded and, with them, opportunities for safety improvement recommendations. It is time to put safety at the top of the health care agenda.

Darren V. Mann, general surgeon, Central