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Sentinel Event Statistics

Sentinel Events Reported by Private Hospitals in 2022 (as at 30 September 2022)

Sentinel Events Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1 Surgery / interventional procedure involving the wrong patient or body part - - - - - 1(0) - - -
2 Retained instruments or other material after surgery / interventional procedure - - 1(0) - - 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) - - - - - - - - 1(1)
7 Maternal death or serious morbidity associated with labour or delivery 1(1) - - - - - - 1(1) -
8 Infant discharged to wrong family or infant abduction - - - - - - - - -
9 Other adverse events resulting in permanent loss of function or death (excluding complications) - - - - - 1(1) - - -
* Number of fatal cases is indicated in bracket.

Summary of Sentinel Event in January 2022:

The DH received notification of a sentinel event from a private hospital on 14 January 2022. The event involved a maternal death of a 39-year-old female who had undergone vaginal delivery at the Hospital on 13 January 2022. The DH initiated investigation immediately and requested the hospital to submit an investigation report in four weeks. The hospitals have submitted the investigation report to 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.

Summary of Sentinel Event in March 2022:

The DH received notification of a sentinel event from a private hospital on 3 March 2022 involving retention of foreign body suspected to be a retained surgical item in a 39-year-old female patient who had undergone laparoscopic surgery at the hospital in 2014. 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 DH. After examining the information provided by the hospital, DH considered there was no evidence of noncompliance with the applicable requirements, including the Private Healthcare Facilities Ordinance (Cap.633), Hospitals, Nursing Homes and Maternity Homes Registration Ordinance (Cap.165), and the relevant Code of Practice in respect of accommodation, staffing or equipment, which contributed to the happening of the event.

Summary of Sentinel Event in June 2022:

The DH received notifications of three sentinel events from private hospitals in June 2022. The first event involved a 97-year-old male patient who had a fall in the ward and died on the next day. The second event involved retained surgical instrument in a 28-year-old male patient who had undergone laparoscopic surgery at the hospital in 2020. The third event involved a 72-year-old patient who had received a beam of radiotherapy with positional deviation.

The DH initiated investigation immediately and requested the hospitals to submit an investigation report in four weeks. The hospitals have submitted the investigation report to DH. The DH will examine the information provided by the hospitals. All concerned private hospitals had taken improvement measures to review and revise relevant policies and procedures. The DH will continue to monitor the implementation of the improvement measures of the respective hospitals.

Summary of Sentinel Event in August 2022:

The DH received notification of a sentinel event from a private hospital on 5 August 2022. The event involved a maternal death of a 30-year-old female who had undergone vaginal delivery at the Hospital on 4 August 2022. The DH initiated investigation immediately and requested the hospital to submit an investigation report in four weeks. The hospital had submitted the investigation report to DH. Initial investigation did not reveal 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.

Summary of Sentinel Event in September 2022:

The DH received notification of a sentinel event from a private hospital on 13 September 2022. The event involved a 48-year-old female patient who walked away from the hospital and later found dead suspected to be caused by suicide. The DH initiated investigation immediately. The hospital had submitted the investigation report to DH. After investigation, the DH did not reveal 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 2022 (as at 30 September 2022)

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 - 3 (0) 3 (0)
2 Patient misidentification which could have led to death or permanent harm - - -
* Number of fatal cases is indicated in bracket.

Highlight in second quarter of 2022

In the second quarter of 2022, three serious untoward event (SUEs) of medication error were reported by private hospitals. The first event involved a patient who was administered wrong dosage of an oral chemotherapy drug. The second event involved a patient who was administered with wrong dosage of intravenous chemotherapy drugs. The third event involved a patient who was given antiarrhythmic drug with incorrect hand written Chinese translation of instructions of dosage on drug bag upon discharge.

Highlight in third quarter of 2022

In the third quarter of 2022, three serious untoward event (SUEs) of medication error were reported by private hospitals. The first event involved a patient who was erroneously administered with a local anaesthetic for which he had a known drug allergy history. The second SUE involved a patient who was erroneously administered with an antibiotic for which she had a known drug allergy history. The third SUE involved a patient who was administered intravenous chemotherapy drug at the wrong rate.

Statistics of Sentinel Events and Serious Untoward Events Reported by Private Hospitals in Previous Years