Public hospitals must now report blunders within 24 hours after string of mishaps
Public hospitals must report medical blunders that could potentially cause death or serious harm to patients to the Hospital Authority within 24 hours, under a new reporting system designed to enhance transparency.
The authority is due to present the reform in a package of new patient-safety measures to Secretary for Food and Health York Dr Chow Yat-ngok in two weeks following a series of medical blunders.
The change targets recent occurrences of hospitals failing to report incidents promptly because no harm had been done to patients, even though the errors were serious.
As well as introducing audits of patient-safety practices and procedures of frontline staff, the authority is amending its two-year-old reporting system to cover events called 'serious adverse incidents'.
The hospitals will have to report to the authority's head office within 24 hours 'serious adverse incidents', meaning events that can potentially cause death or serious harm.
Currently, it is mandatory for hospitals to report 'sentinel events', meaning incidents having already caused death or serious harm. That includes surgery involving a wrong patient or body part, and medication errors resulting in permanent major loss of function or death of a patient.
Minor incidents are reported voluntarily by hospitals.
For both 'serious adverse incidents' and 'sentinel events', hospitals will have to present an interim investigation report within two weeks and a final report within six weeks.
Not all cases will be made public. The authority will decide under what circumstances it should report cases to the media.
A doctor familiar with the reporting system said: 'In the future, hospitals have to report events that pose a high risk, such as a wrong injection of morphine or wrong vaccination of babies. The authority hopes that the change can restore public confidence by a prompt reporting of incidents.'
A series of blunders in recent weeks has caused a public outcry and embarrassed the authority.
On Saturday, Prince of Wales Hospital reported that a baby was wrongly injected with an antibiotic, while North District Hospital on Friday reported a blunder in which a terminally ill patient with breast cancer was mistakenly injected with morphine meant to be taken orally. The patient died seven days later.
In other blunders, babies at Queen Elizabeth Hospital were injected with an expired vaccine, and two babies were mistakenly swapped at birth. In some cases, the hospitals decided to make public the incidents only after media inquiries.
Chow has also instructed the authority to have more consistent disciplinary action for staff. Staff responsible for blunders are disciplined by individual hospitals. There are no clear guidelines on punishment.
The authority plans to set up a 'disciplinary and professional competency panel' to act as a 'central court' for disciplinary actions against staff involved in serious incidents.
The doctor familiar with the reporting system said: 'At present, the authority's human resources policy focuses more on any negligence or misconduct of staff. The new panel will look at the professional competency of staff and decide on disciplinary action and training needs.'
Dr Luk Che-chung, chief of the authority's Kowloon East cluster, supported prompt reporting of adverse incidents, saying that it could enhance transparency.
'I don't think the new measure will have much impact on our workload, because we have been reporting those incidents. The change means we have to report those incidents more quickly.'
Luk said that whether the incidents should be made public would depend on how much public interest was at stake.
