Transparency key to reducing number of hospital blunders
The case of a newborn falling out of her incubator highlights the need for the clear reporting of errors – human or otherwise
Only a few weeks ago a senior official attempted to reassure Hongkongers after the Hospital Authority revealed a spate of medical blunders in the fourth quarter of last year. Undersecretary for Food and Health Sophia Chan Siu-chee said the authority had a mechanism to follow up on the cases and make improvements. It needs to go into overdrive to reassure an incredulous public after a 24-day-old girl fell out of an incubator in the Special Baby Care Unit at Kwong Wah Hospital in Yau Ma Tei. Tsui Hoi-ki, under observation for a respiratory problem, was later found to have suffered a small brain haemorrhage. She was last reported to be in a stable condition.
A hospital spokesman said an expert investigation panel is on the case. The hospital says a nurse had confirmed the incubator was properly closed. Fifteen minutes later, she found the baby crying on the floor, with one of the incubator windows open.
The baby’s father claims a nurse told him his daughter might have kicked open a window on the incubator and fallen out, an explanation he found hard to accept because he considered his daughter was too weak to do so. Paediatrician Anthony Ng Wing-keung also questioned such an explanation for the same reason – so long as the incubator was in good condition.
It is good therefore to hear the Hospital Authority respond to the father by saying it is investigating and a police spokesman say the force is investigating a report by the girl’s grandmother. There are many questions to be answered. We need to know much more detail before forming any conclusions. It is therefore important that the investigation be open and transparent. The public expects to see who should bear responsibility. In that regard, the authority has observed a policy of prompt reporting and follow-up of blunders involving patient safety since 2008. That remains important to maintaining public confidence. Medical treatment can never be free of risk or human error. Transparent reporting ensures blunders are not swept under the carpet and, hopefully, that steps are taken to prevent repetition.
