Sentinel Events Reported by Private Hospitals in 2021
| Sentinel Events | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Surgery / interventional procedure involving a wrong patient or body part | - | - | - | - | - | - | - | - | - | - | - | - |
| 2 | Retained instruments or other material after surgery / interventional procedure | - | - | - | 1 (0) | - | - | - | - | - | - | 1(0) | 2(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 inpatient 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.
Summary of Sentinel Event in November 2021:
The DH received notification of a sentinel event from a private hospital on 29 November 2021 involved retention of foreign body suspected to be a retained instrument in a 44-year-old female patient who had undergone laparoscopic surgery at the Hospital in 2015. The foreign body was removed by laparoscopy in the concerned private Hospital. 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 Events Reported by Private Hospitals in Year December 2021:
The DH received notification of two sentinel events from two private hospitals on 1 and 4 December 2021 respectively. The first event involved retention of instrument in a 69-year-old male patient who had undergone surgery at the hospital in November 2020. The second event involved a retained gauze in the vagina of a 24-year-old female patient who had given birth at the hospital in October 2021.
The DH initiated investigation immediately and requested the hospitals to submit an investigation report in four weeks. Both hospitals have 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.
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.
Highlight in third quarter of 2021
In the third quarter of 2021, three SUEs of medication error were reported by private hospitals. The two events involved inadvertent administration of insulin and an anaesthetic drug respectively. The third event involved a patient who was administered with a dose of anti-coagulant which was supposed to be discontinued.
Highlight in fourth quarter of 2021
In the fourth quarter of 2021, two SUEs of medication error were reported by private hospitals. The first event involved erroneous administration of an antibiotics to a patient with known drug allergy. The second event involved a patient who was erroneously administered with an oral hypoglycemic drug.
Serious Untoward Events Reported by Private Hospitals in 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) | 3(0) | 2(0) |
| 2 | Patient misidentification which could have led to death or permanent harm | - | - | - | - |