Source:
https://scmp.com/comment/insight-opinion/article/2093849/one-way-or-another-we-need-put-end-medical-blunders
Opinion/ Comment

One way or another, we need to put an end to medical blunders

Doctors can make mistakes but when such errors occur, it is incumbent upon those involved to inform patients and the authorities immediately

Doctors can make mistakes but when such errors occur, it is incumbent upon those involved to inform patients and the authorities immediately

Medical blunders have occurred much too frequently in Hong Kong’s hospitals in recent years. They have caused public concern and prompted promises that improvements will be made.

The latest scandal , which led to a woman suffering acute liver failure, shows lessons still need to be learned. The blunder was a serious one with very serious consequences. Tang Kwai-sze, 43, was treated by two doctors at the United Christian Hospital in Kwun Tong in January and February. She was given steroids for a kidney condition. But the doctors failed to prescribe an anti-viral drug as a precaution. Without that medicine, Tang, suffering from hepatitis B, was at risk of acute liver failure. Sadly, that is what happened to her in April.

The patient’s plight came to public attention because of a heart-rending appeal by her teenage daughter, who wanted to donate part of her liver to save her mother’s life. She was three months short of the legal age for doing so, but another donor stepped forward. This first transplant did not work, but a second operation was successful. Tang, however, is in a critical condition battling a fungal infection.

The blunder was not made public until more than a month after the hospital discovered it on April 6, when checking the patient’s records. It did not inform her family until April 19 and the Hospital Authority was not told until April 20. The delay in revealing the mistake is unacceptable. The family and Hospital Authority should have been notified within 24 hours. Even the doctor currently treating Tang, at a different hospital, was not aware of it until he checked medical records. It is disturbing that the error was only revealed when the family of the patient pressed for information.

Michelle, the daughter of patient Tang Kwai-sze leaves Queen Mary Hospital in Pok Fu Lam. The hospital did not inform her of the blunder until 13 days after the mistake was discovered. Photo: Felix Wong
Michelle, the daughter of patient Tang Kwai-sze leaves Queen Mary Hospital in Pok Fu Lam. The hospital did not inform her of the blunder until 13 days after the mistake was discovered. Photo: Felix Wong

The delay may have been partly caused by a doctor being on leave, but that is no excuse. This is not the first time the United Christian Hospital has been involved in controversy over blunders. In 2014, a pathologist at the hospital misread the health reports of 118 patients. Last year, the health minister called for a review of procedures in public hospitals after a four-month delay in telling a patient she had signs of ovarian cancer. The hospital has apologised for the blunder in treating Tang and an investigation is under way. Consideration should be given to referring the matter to the Medical Council for disciplinary proceedings.

Doctors are not miracle workers and mistakes will occur at times, especially when hospitals are busy. But patients are entitled to expect doctors not to make basic errors, especially when the potential impact on their health is serious. And when mistakes are made, they have to be reported quickly. Steps must be taken to ensure that similar blunders do not occur in future.