Panel blames lack of vigilance by doctors for liver blunder at Hong Kong hospital
Panel reports that specialists facing heavy workload failed to give hepatitis B sufferer Tang Kwai-sze anti-viral drug, leading to liver failure and two transplants
A lack of vigilance by two specialists amid a heavy workload was to blame for a blunder that led to the liver failure of a woman who later needed two transplants, an investigative panel said on Tuesday.
The panel declined to reveal whether any staff had been penalised over the incident. The pair are still working at United Christian Hospital in Kwun Tong.
It also ruled out the possibility that the public hospital had covered up the incident but admitted there was a delay in reporting it because staff lacked experience in handling such cases.
Hepatitis B sufferer Tang Kwai-sze, 43, had acute liver failure in January after the doctors prescribed her a high dose of steroids for a kidney complaint without giving her an anti-viral drug to prevent her from suffering potentially fatal side effects.
Tang was transferred to Queen Mary Hospital in April for two liver transplants. She is still under intensive care and remains in critical condition.
The panel said the doctors made the error despite noticing an automatic reminder in the computer system that warned them of the risks involved.
“The major reason for the mistake was an insufficient level of vigilance,” said panel member Professor Daniel Chan Tak-mao, chair professor in the medicine department at the University of Hong Kong.
“The doctors have enough knowledge about the risk and had prescribed the anti-viral drugs to other patients with Hepatitis B according to their records. But they were not sticking to the old way of doing it this time,” Chan said.
“We believe they might have wanted to handle the heavy patient load as soon as possible and had neglected the important information.”
Chan added medical staff at United Christian Hospital lacked experience in dealing with medical blunders and “had a tendency to rely on their seniors to handle situations”, resulting in a delay in reporting the case to the Hospital Authority.
The authority said an independent panel was now reviewing the reporting of blunders to ensure it was done in a timely manner.
Another panel member, Dr Liu Shao-haei, did not reveal whether the two doctors would be punished, stressing the authority had another mechanism to handle personnel management.
The panel suggested the hospital enhance staff training, ease the manpower shortage, upgrade its computer system and improve communication skills with patients and their relatives.
A spokesman for the hospital said it accepted the findings of the investigation and would implement its recommendations to prevent repeating the mistake.
Democratic Party lawmaker Helena Wong Pik-wan expressed disappointment and urged the Medical Council to rule that the doctors were responsible.
The patient’s daughter, Michelle, who visited her mother on Tuesday, declined to comment o.n the report.
Public hospitals across Hong Kong face a shortage of some 250 doctors.
Dr Ng Chi-ho, former president of the Public Doctors’ Association, said the public health system was overloaded and that doctors in specialist outpatient clinics handled about 30 cases in three hours, meaning they had just six minutes on each case.
Secretary for Food and Health Professor Sophia Chan Siu-chee admitted that manpower shortages were a problem, but said different measures were being employed to improve the situation.Tang’s case drew attention after Michelle, who was three months shy of the legal age of 18 to donate her own liver to save her mother, made a public appeal. It prompted a government review of the donation policy.
A stranger, Momo Cheng Hoi-yan, 26, came to the rescue and donated two-thirds of her liver. But the new organ did not function well and about a week later Tang received a second transplant, this time from a deceased donor.