Sentinel Events Reported by Private Hospitals in 2021 (as at 31 August 2021)
|1||Surgery / interventional procedure involving the wrong patient or body part||-||-||-||-||-||-||-||-|
|2||Retained instruments or other material after surgery / interventional procedure||-||-||-||1 (0)||-||-||-||-|
|3||ABO incompatibility blood transfusion||-||-||-||-||-||-||-||-|
|4||Medication error resulting in major permanent loss of function or death||-||-||-||-||-||-||-||-|
|5||Intravascular gas embolism resulting in death or neurological damage||-||-||-||-||-||-||-||-|
|6||Death of an in-patient from suicide (including home leave)||-||-||-||-||-||-||-||-|
|7||Maternal death or serious morbidity associated with labour or delivery||-||-||-||-||-||-||-||-|
|8||Infant discharged to wrong family or infant abduction||-||-||-||-||-||-||-||-|
|9||Other adverse events resulting in permanent loss of function or death (excluding complications)||-||-||-||-||-||-||-||-|
Summary of Sentinel Event in April 2021:
The Department of Health (DH) received a notification of a sentinel event from a private hospital on 4 April 2021. The event involved retained guidewire in a central venous catheter in an 82-year-old male patient which was revealed on 4 April 2021. The DH initiated investigation immediately and requested the hospital to submit an investigation report in four weeks. The hospital has submitted the investigation report to the DH. After examining the information provided by the hospital, the DH considered there was no evidence of non-compliance with the requirements of the Private Healthcare Facilities Ordinance (Cap.633) or the Code of Practice for Private Hospitals in respect of accommodation, staffing or equipment, which contributed to the happening of the event.
Serious Untoward Events Reported by Private Hospitals in 2021 (as at 30 June 2021)
|Serious Untoward Events||Jan-Mar||Apr-Jun||Jul-Sep||Oct-Dec|
|1||Medication error which could have led to death or permanent harm or carries a significant public health risk||1(0)||2 (0)|
|2||Patient misidentification which could have led to death or permanent harm||-||-|
Highlight in first quarter of 2021
In the first quarter of 2021, one serious untoward event (SUE) of medication error was reported by private hospitals. The case involved erroneous administration of a non-steroidal anti-inflammatory drug to a patient with known drug allergy.
Highlight in second quarter of 2021
In the second quarter of 2021, two SUEs of medication error were reported by private hospitals. The first event involved a patient who was administered with wrong infusion rate of inotropic/ vasopressor medication. The second event involved a patient who was administered with wrong dosage of inotropic/ vasopressor medication.