A painful lesson for the health system

PUBLISHED : Saturday, 25 August, 2007, 12:00am
UPDATED : Saturday, 25 August, 2007, 12:00am

The Hospital Authority and Prince of Wales Hospital had braced themselves for yesterday's publication of the report of an inquiry into a medical blunder that killed a young woman. The inquiry head, an expert from Canada, had already foreshadowed disturbing findings and recommendations for a serious shake-up of specialist training and internal systems that should have prevented a doctor's fatal error.

It is hard to argue with his conclusions. The blunder - injecting a chemotherapy drug by the spinal route instead of intravenously - was the 55th similar case reported to the World Health Organisation in 40 years. The fatality rate is very high. The risk was well known.

Hopefully, the report will provide the woman's family with some comfort, along with trust that the cruel circumstances of her death while in complete remission from leukaemia will help prevent further tragedies. There is room also for compassion for the doctor in her sad personal and professional ordeal. The flaws in the system should not be overlooked when she is held to account.

The hospital and the Hospital Authority, too, can move on, stronger for an independent and transparent investigation into what went wrong and why. But they must take to heart the advice added yesterday by inquiry chairman Ian Tannock, that because human errors are bound to occur in administering medication there must be in place as foolproof a system as possible, with as many checks as possible as an added safety net.

Unfortunately, the inquiry findings follow a recent rash of medical blunders. But the fact that they are coming to light is healthy, and no reason for the public to lose confidence in the system. Public health care in Hong Kong remains among the best in the world. That is a credit to our doctors and nurses, who bear the strain on resources of access for all to cheap, high-quality health care.

The investigation flags a new policy of openness and transparency. Under an approach to be adopted from October, medical mistakes will be openly reported, analysed and the lessons learned applied in all public hospitals. That may represent a painful change of culture, but it is one that must be embraced.