Medical mishaps blamed on lack of team spirit
A lack of team spirit among frontline health care staff is the main reason for some of the recent medical blunders, a hospital chief said.
A spate of incidents at public hospitals, including medication errors and the misidentification of a baby, has caused public concern and prompted Secretary for Food and Health Dr York Chow Yat-ngok to call for improvements.
Fung Hong, the chief executive of the New Territories East cluster of hospitals, where two of the errors occurred, said most medical blunders were not the result of problems with individuals or the system, but of poor teamwork.
'The authority and hospitals have very clear guidelines and procedures. Nurses know the proper medication and labelling procedures. They are all very professional and they do care about patient safety,' Fung said. 'What I can see is a lack of team spirit on the front line. In some cases, health care workers do not show adequate co-operation and team spirit.
'Each nurse has to take care of eight to 10 patients at one time and they have to make hundreds of clinical decisions in each shift. It is not an easy job. If staff can remind each other of high-risk areas and possible errors, patient safety can be enhanced.'
Fung said the hospitals he is in charge of plan improvements to nurses' shift-handover procedures.
On Saturday, Prince of Wales Hospital in Sha Tin reported that the wrong baby had been given an antibiotic. On Friday, North District Hospital reported that a nurse had mistakenly injected a terminally ill breast cancer patient with morphine meant to be administered orally. The patient died seven days after the incident, but the hospital and an independent pharmacist said it was unlikely to have hastened the woman's death.
The Hospital Authority has said it will begin special patrols to see how well staff are complying with safety procedures. Each of the seven hospital clusters will set up teams led by a senior doctor to conduct the 'patient safety rounds'. Such teams have sometimes been led by more junior staff. The authority held a high-level meeting yesterday to discuss the patrols.
Dr Luk Che-chung, who is in charge of hospitals in East Kowloon, backed the stepping up of patient-safety audits. 'Perhaps the seven clusters can conduct some audit exercises together, so we can learn from each other,' Luk said.
One of the hospitals he is responsible for has already done just that. United Christian Hospital's first patient safety round was jointly run with Tuen Mun Hospital in October. More than 30 senior staff from the two hospitals visited the wards and departments in each other's hospital.
Anne Kwan Siu-king, director of quality and safety for the East Kowloon hospitals, said: 'We learned from each other through this cross-hospital audit. For example, we borrowed the experience of Tuen Mun Hospital to put blood samples in fixed containers instead of plastic bags to avoid spills. Tuen Mun Hospital studied our practice of putting tips on computer screen-savers, about to how to avoid medication errors.'
As well as United Christian Hospital in Kwun Tong, Luk is in charge of Tseung Kwan O Hospital.
Kwan said the two patient-safety audits these hospitals had conducted since last year had found the three biggest risks to safety were medication errors, missing labels on patients' specimens and falls by patients, particularly elderly patients.
Kwan said safety 'auditors' must have a good manner to avoid resistance from staff.
'We do not want to give the impression that we are there to order them to do this or that. We want them to understand that we are there to help them and listen to their problems. We show appreciation if we spot good practices,' she said.
The team encourages staff to report big and small incidents, even things like slippery floors or a single tablet of a common drug such as Panadol going missing.
'By knowing about even minor incidents, we can have an idea if these are common problems or not,' Kwan said.