Patient safety must always come first
In the wake of the latest medical blunder, an independent panel appointed to review the reporting of errors should restore a protocol that is the foundation of accountability, openness and transparency, and ensures constructive steps are made to prevent recurrence
An investigative panel has filed its report on a medical blunder that turned into a heart-rending transplant drama. It raises a number of public health issues. The panel found that a lack of vigilance by two hospital specialists resulted in failure to prescribe anti-viral drugs to prevent liver complications in a hepatitis B carrier being treated with steroids for a kidney complaint. The blunder, at the United Christian Hospital in Kwun Tong, came to light when the woman, 43, needed a liver transplant. When her teenage daughter was ruled too young to donate a stranger stepped forward, only for the transplant to fail. The patient received a second, this time from a deceased donor. She remains in hospital in critical condition.
The panel’s report said the doctors erred despite an automatic reminder in the computer system about the risks and that the blunder had happened amid a heavy workload. This raises the question whether this mitigates any blame. We can all empathise with doctors who are stretched by staff shortages to keep up with the patient load. But patient safety comes first. The panel did not reveal whether the doctors had been held accountable. The Hospital Authority must see that responsibility is fairly and openly apportioned between contributing factors so that appropriate action can be seen to be taken. Meanwhile, it is good to see the hospital pledge to enhance training, ease staff shortages, upgrade its computer system and communicate better with patients and families.
Hong Kong is no stranger to medical blunders. A rash of them years ago resulted in a protocol for prompt reporting and investigation to maintain public confidence. But you would not know it from the latest case, in which the blunder was not made public for more than a month. Doctors and nurses are human and mistakes will occur despite the best personal and systemic efforts to prevent them. But the public expects doctors not to make basic errors with serious consequences. For the sake of public confidence, we trust that an independent panel appointed to review the reporting of errors restores a protocol that is the foundation of accountability, openness and transparency, and ensures constructive steps are made to prevent recurrence.