Cancer patient dies after doctor overlooks hepatitis B
A cancer patient died after a doctor failed to read her medical report proprly and assumed the patient did not suffer from hepatitis B. As a result, the doctor failed to administer crucial antiviral therapy during treatment for her lymphoma.
The blunder was revealed in the Hospital Authority's risk alert bulletin, released yesterday. The authority would not disclose the identity of the doctor, the hospital involved or whether the doctor had been subject to any disciplinary proceedings.
The bulletin said the patient, who was scheduled for chemotherapy, had been checked for hepatitis B as part of the standard pre-chemotherapy testing. The positive result was screened and signed by the doctor, identified as Doctor A.
The same doctor prescribed chemotherapy for the patient. 'In the process, Dr A inadvertently assumed the patient's [hepatitis B] status to be negative. Hence ... antiviral therapy was not prescribed,' the bulletin said.
Four months later, after her fifth course of chemotherapy, the patient's liver function became abnormal. Medical staff reviewed the case and the earlier positive test result was discovered.
The medical team immediately gave her antiviral therapy for acute hepatitis caused by the reactivation of hepatitis B. But she developed acute liver failure and died four weeks later despite receiving aggressive antiviral therapy and intensive medical support.
The report attributed the blunder to both human and system factors.
Besides the doctor's assumption of the patient's hepatitis B status - a consequence of not referring to the actual laboratory report - the authority also concluded that the blunder involved a systemic factor: the medical staff did not use a checklist to go through thoroughly the patient's critical clinical information prior to the start of chemotherapy treatment.
The bulletin said lymphoma patients receiving a high dose of glucocorticoids in their chemotherapy were at high risk of reactivating a hepatitis B infection.
Therefore, it said, antiviral therapy should be given before the start of the cancer treatment.
Tim Pang Hung-cheong, a spokesman for the Patients' Rights Association, said he was shocked by 'such a serious medical blunder'.
'Lymphoma patients are a high-risk group and we would have assumed medical workers would pay extra attention to their cases. How would a doctor design the treatment for patients based on assumptions instead of properly reading through the medical reports?'
Pang urged the family of the deceased to contact the association for help in following up the case.