Panel finds Hong Kong surgeon operated on the wrong side of patient’s skull because he did not check scans
The emergency surgery was started before the brain scan images were uploaded to the hospital’s system
A public hospital surgeon cut open the wrong side of a woman’s skull because he did not check the patient’s brain scan images immediately prior to the surgery.
The patient, a 54-year-old woman, was admitted to Tseung Kwan O Hospital on March 7 suffering from severe headaches, drowsiness and vomiting. She was found to have a severe intracranial haemorrhage and fluid build-up in the brain, and was transferred to Queen Elizabeth Hospital for urgent treatment.
A scan revealed she had an aneurysm and bleeding on the right side of her brain, causing an increase in intracranial pressure.
A Hospital Authority panel set up to investigate the severe medical blunder, which revealed their findings on Friday, said doctors had to arrange an urgent craniotomy because the patient was in a “critical and life-threatening condition”.
However, the emergency surgery was started before the brain scan images were uploaded to the hospitals system.
The panel found that the neurosurgeon then arranged for the left craniotomy “based on his recollection” of the images. He also did not mark the surgical site on the patient’s skull before the operation.
It was only after the scan images were uploaded to the system and verified by an anaesthetist that the medical team realised that they were operating on the wrong side of the brain.
The seven-member panel concluded that the surgical team had followed protocol and performed the appropriate checks before the operation, which included verifying the patient’s identity, the surgical site and any adverse drug reactions.
But it also urged the hospital to enhance patient safety, to upload images to the system for checking before operations, and to review its list of preoperative checks. It also said the hospital should consider introducing a second round of checks.
A hospital spokesman accepted the panel’s findings and said it had implemented some of the recommendations. Such improvement measures would also be rolled out to other public hospitals in the city.