Hong Kong brain surgeon drills hole in wrong side of patient’s head
It is the second brain surgery blunder to happen in the city within the space of four months
A doctor at a Hong Kong public hospital performed surgery on the wrong side of an 86-year-old man’s skull – the second brain surgery blunder in the city in just four months.
An investigation has been launched after the Princess Margaret Hospital doctor performed surgery on the right side of the patient’s head, when it should have been done on the left.
Four months ago, a Queen Elizabeth Hospital neurosurgeon wrongly performed surgery on the left side of the brain of a 54-year-old woman, while it was the right side that required treatment.
In the latest case, the elderly man was admitted to the Princess Margaret Hospital’s neurosurgery ward on Wednesday after suffering an accumulation of blood between the layers of tissue around the brain. He was set to have an urgent burr hole operation on the left side of his skull to remove the blood clots.
When few clots were seen after opening a thick part of the membrane outside the brain, the neurosurgeon realised the error.
The doctor then closed the wound on the right side and proceeded to remove the blood clots on the left side of the brain.
The patient regained consciousness and has been in a stable condition since the operation.
The incident was reported to the Hospital Authority head office on the day of the operation. The hospital also informed the patient’s family of the mistake on the same day and apologised to them.
An investigation panel will be formed to find the cause of the blunder and a report will be submitted to the authority within eight weeks.
The authority has also issued an internal reminder to relevant clinical staff on Friday on the importance of carrying out “time-out” procedures, meaning steps such as confirmation of patient’s identity and which part of the body needs surgery before operations.
A surgical safety policy applying to all public hospitals is also being finalised to improve the effectiveness of checking procedures before operations.
In the previous case in March, the Queen Elizabeth neurosurgeon, who performed surgery for a patient who suffered from an aneurysm that caused an increase in intracranial pressure, was found to cut on the wrong side only after removing part of the patient’s left skull to drain the brain fluid.
An anaesthetist spotted the error while reviewing the patient’s report.
An investigation report for the case which was released in May found the doctor performed the surgery based on his recollection of the preliminary computed tomography image only.