New hospital blunder admitted

PUBLISHED : Thursday, 04 October, 2007, 12:00am
UPDATED : Thursday, 04 October, 2007, 12:00am

Unsterilised equipment used for neurosurgery on patient at Queen Elizabeth

Unsterilised equipment was used to perform neurosurgery on a patient at Queen Elizabeth Hospital after medical staff mistakenly rinsed an ultrasound probe in water instead of in an antiseptic solution.

The same sterilised water in which the instrument was rinsed before and after the operation was later also mistakenly used to clean equipment used to perform four prostate operations, the hospital admitted yesterday.

The four prostate surgery patients, who are aged between 70 and 89, run the risk of cross-contamination. However, a blood test on the neurosurgery patient, a 25-year-old man, showed he did not have any condition which could passed to the four prostate patients, said the chief executive of the Kowloon Central hospitals cluster, Hung Chi-tim.

Dr Hung said the four had been prescribed antibiotics.

Tuesday's incident is the latest in a string of medical blunders, but the first to be revealed since the Hospital Authority revamped its system for reporting medical incidents.

The five patients are stable in hospital.

Dr Hung said: 'We have explained the situation to the patients and their relatives, and the hospital's apology was conveyed.'

A risk assessment had been carried out on the patients, and an initial investigation into what had happened. No other patients were involved, Dr Hung said.

The hospital has set up a four-man investigating team, headed by a United Christian Hospital operating theatre manager.

The team will submit its report to the Hospital Authority within eight weeks.

According to Dr Hung, the ultrasound probe should have been sterilised in a new antiseptic solution, introduced to the hospital only two weeks ago.

It is known as Cidex opa, and is light blue in colour and odourless. Previously the solution used had been Cidex, which is green with a strong odour.

After using the solution, tools are rinsed in sterilised water to wash off the antiseptic.

Dr Hung said a preliminary investigation showed labels were missing from the trays containing the antiseptic solution and sterilised water. He said the incident involved different medical staff and it was hard to determine who should be responsible until the investigation team filed its report.

The case came to light only when a staff member found that the ultrasound probe had been in the tank of water for a long time, and realised the tank did not contain the new antiseptic solution.

The hospital failed to explain why the same tank of water was used for instruments used in the four separate prostate operations.

Officials said the investigation team would look into this.

In November, a similar blunder was discovered at Caritas Medical Centre. Surgical knives which had not been fully sterilised were found to have been used in cataract operations on 13 patients.