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Colleen Lee

Hospital cluster reports large drop in specimen mix-ups
A new bar-code system for labelling blood samples has helped prevent specimen mix-ups at hospitals, the New Territories East cluster says.
Its figures show the incidence of incorrect labelling of blood specimens have plummeted  since the system came into full operation in July.
Under the system,  staff who want to print blood-sample labels have to first scan a  bar code on a patient's wristband.  They then  scan the bar code on a document with the patient's particulars.  The labels will only be printed if the two bar codes match.
In the past, there was no such bar-code scanner and medical staff could print  labels whenever necessary.
'There was higher risk of mixing up labels and sticking wrong labels on blood specimens,' said Lui Siu-fai, New Territories East cluster service director (quality and risk management).
The cluster covers Alice Ho Miu Ling Nethersole Hospital, Bradbury Hospice, the Cheshire Home Shatin,  North District Hospital, Prince of Wales Hospital, Shatin  Hospital and Tai Po Hospital.
In the first six months of the year, there was an average of seven incidents of incorrect labelling of blood specimens each month in the  cluster. But from July to September, only two incidents were reported - one in July and another in September. Dr Lui said those two errors were quickly corrected and did not cause any harm to patients.
Cluster chief executive Fung Hong  said: 'We hope to minimise the number of [medical] blunders, but it is difficult to say whether there will be no errors at all. There are many human factors which are out of our control.'
With the help of advances in the Hospital Authority's medical system and increasing awareness of patient safety among staff, he hoped to see fewer  blunders.
In September 2004, a 74-year-old woman was given the wrong blood type in a transfusion at the Prince of Wales Hospital. It was later found that an intern had taken a blood sample from another patient and labelled it as coming from the woman.
The blunder came to light when she developed fever and chills about an hour into the  transfusion.  A subsequent transfusion was safely carried out.
Meanwhile, to strengthen its work on patient safety and to lower the risk of mix-ups, Dr Fung said the cluster had set up a six-member patient-safety team this month, the first of its kind among the authority's seven clusters.
He said a roving team of five  nurses and a  pharmacist was stationed at the cluster's hospitals to carry out regular safety inspections.
Dr Lui added that by the end of the year the cluster would start giving every discharged patient  a printed card listing all drugs to which they were allergic.
'In the past, we handwrote the drug names, and it was easy to make mistakes,' he said, adding that such allergy cards could help  private doctors with no access to the authority's allergy database  prescribe drugs.



New labelling system cuts number of blood blunders