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Sammy Heung

Staff at a Hong Kong public hospital injected a patient with 10 times the prescribed dose of a sedative last month, the latest in a string of recent medical blunders.
Tuen Mun Hospital said on Friday that the patient had visited its accident and emergency department on October 18 and was transferred to its intensive care unit (ICU) because of a medical condition.
“In the emergency department, the patient was prescribed sedation to assist the subsequent medical procedures,” a hospital spokesman said.
“Before being transferred to the ICU, medical staff discovered that the dosage of the sedative injection received by the patient was 10 times the prescription.”
The spokesman said the patient was sent to the ICU according to the initial arrangement and showed no abnormal reactions, while remaining under close monitoring by medical staff.
The patient is in a stable condition and has been transferred to a general ward.
The hospital declined to reveal the patient’s gender or age, citing privacy concerns.
It said it was very concerned about the mix-up and had contacted the patient’s family to explain and apologise.
“After the incident, the hospital reminded its staff to follow the guidelines to handle and check the dosage of injected drugs carefully, and review the workflow of the emergency department,” the spokesman said.

The Hospital Authority’s head office has been told about the case through an incident reporting system.
A committee had been established to investigate the cause and to recommend improvements, the hospital said.
A source said the sedative drug involved was ketamine.
Public hospitals have been involved in a number of blunders recently, including one last month in which a 76-year-old patient had a laxative delivered to his lung rather than his stomach after an intern doctor misread an X-ray scan.
In June, another intern doctor’s erroneous assessment of an X-ray scan similarly led to the wrongful placement of a feeding tube in a 61-year-old patient’s lung at Queen Elizabeth Hospital in Yau Ma Tei.
Secretary for Health Lo Chung-mau last month said the repeated mishaps could no longer be seen as individual cases but pointed to a “systemic problem”.
The authority in July formed a committee to review the management of the public hospital system. Lo revealed earlier that a report, with more than 30 recommendations, had been submitted to the Health Bureau in early October.
Society of Hospital Pharmacists of Hong Kong president So Yiu-wah said ketamine was controlled under the Dangerous Drugs Ordinance.
“Ten times the normal prescription may make a person’s breath become slower and shallow. Each breath will not be enough for the body,” he said.
“A ventilator is required to pump oxygen into the patient’s lung to increase the blood oxygen level.”
So said hospitals should keep ketamine in one dose size to avoid mix-ups.
He said a nurse would normally retrieve the drug in vial form and hand it to a nurse or doctor in the emergency department.
“Both of them will check if the drug and dosage are correct,” he said. “We have a counter-check system that involves checking by two people.”
So said such incidents were rare in Hong Kong.
He said in Australia in 2021 a patient was also injected with ketamine 10 times the prescription and required oxygen support.
The Australian hospital kept ketamine in both 10 milligram and 100mg dosages, and the staff used the larger one, he added.
Alex Lam Chi-yau, chairman of advocacy group Hong Kong Patients’ Voices, called the mix-up a “serious” medical incident and said sedatives needed to be handled with caution.
“We are concerned that this incident might involve some human negligence,” he said, calling on the hospital to report to relevant authorities including the Medical Council and the Nursing Council if professional misconduct was found to be involved.
He also urged the Hospital Authority to explain to the public why it only disclosed the case after media inquiries rather than revealing it earlier.
“Was there something hidden behind it if the public was not notified about the incident for more than two weeks?” he said.


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Hong Kong public hospital gave patient 10 times prescribed sedative dose in medical blunder

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Tuen Mun Hospital says the patient visited on October 18. Photo: Dickson Lee

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Dr David Lam on Friday questioned hospitals’ “communication mechanism”, noting that an experts had recently made recommendations on how to avoid accidents such as the one that happened on Wednesday. Photo: K. Y.

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Hong Kong

Health & Environment

Tuen Mun Hospital says patient monitored after injection and showed no abnormal reaction


Tuen Mun Hospital says patient monitored after injection and showed no abnormal reaction.


Accidents and personal safety in Hong Kong

Hong Kong society

Hong Kong public hospital gave patient 10 times prescribed sedative dose in medical blunder

.css-1c6uqr6{color:inherit;font-weight:inherit;font-size:inherit;font-family:inherit;line-height:inherit;overflow-wrap:break-word;}Tuen Mun Hospital says patient monitored after injection and showed no abnormal reaction

Tuen Mun Hospital says patient monitored after injection and showed no abnormal reaction