Princess Margaret Hospital announces root cause analysis investigation on sentinel event


Hong Kong (HKSAR) - The following is issued on behalf of the Hospital Authority:

     The spokesperson for Princess Margaret Hospital (PMH) today (September 8) released the findings and recommendations of a root cause analysis investigation on a sentinel event, which was announced earlier by the hospital.

     PMH announced a sentinel event concerning a burr hole operation on the wrong side on July 14 this year. The burr hole operation was conducted on the right side but should should have been conducted on the left side. Subsequent to the incident, the hospital appointed a panel to investigate the underlying causes and also to make recommendations to prevent future recurrence. The panel completed the investigation and the report has been submitted to Hospital Authority Head Office and PMH.

     An 86-year-old male patient presented with subdural haematoma was admitted to the Neurosurgical Ward in PMH on July 12 for an emergency left-side burr hole operation to drain out the blood.

Before performing the operation, the operation side was marked on the left ear lobe of the patient by a doctor in the ward. The patient was then sent to the operating theatre. The operating team conducted the "Time Out" checking procedure to ensure the correct identity of the patient and the operating site.

After the "Time Out" check, members of the operating team were busy with their own tasks in preparing for the operation. The chief surgeon explained the procedure to an assistant doctor and performed surgical preparations including hair shaving and skin disinfection. The scalp incision line marking was erroneously put on the right side.

The operation started after about half an hour. During that period, the operating team did not notice the incorrect head positioning and scalp incision marking, which did not match with the original operation side marked on patient's left ear lobe.

     As minimal blood clotting was seen after opening the dura on the right side during the operation, the doctor then noticed that the operation was being done on the incorrect side. The doctor closed the wound on the right side and proceeded to drain the blood clots on the left.

The patient regained consciousness and has been stable since the operation. He was discharged on July 24. The incident has been explained to the patient and his family and an apology was also given.

     The Investigation Panel has interviewed the staff members concerned and examined the workflow.

The Panel concluded in its findings that the following two factors are believed to have contributed to the incident:
  1. The original operation site marking on the left ear lobe of the patient was not conspicuous once the doctor stood on the vertex side of the patient;
  2. The correct side of the operation had not been re-checked before marking of the incision lines.

     The Panel has made the following recommendations to the hospital:
  1. Mark the operation site on the forehead of the patient to enhance visibility;
  2. (a) To perform "Sign In" and "Time Out" separately and distinctively: "Sign In" involving only the anaesthetist, nurse and patient before induction, and then “Time Out” performed by the whole team just before the incision marking is made; or
    (b) To perform a second "Time Out" before marking of incisions to finally check the correct operation and correct site for operation involving laterality, positioning and/or multiple operating sites.

     PMH has explained the investigation to the patient and his family and would like to extend its sincere apology again to the patient. The hospital will implement and follow up the recommendations made by the Investigation Panel to prevent similar incidents from happening again. The incident will be followed up in accordance with established human resource procedures.

Appreciation was also extended to the Chairman and members of the Investigation Panel. Membership of the Panel was as follows:
 
Chairman
-----------
Deputy Chief of Service (Neurosurgery), Kwong Wah Hospital/Representative from Clinical Co-ordinating Committees (Neurosurgery), Hospital Authority
Dr Wong Hoi-tung

Members
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Chief Manager, Kowloon West Cluster/Deputy Hospital Chief Executive (Operations), Princess Margaret Hospital/Deputy Hospital Chief Executive, North Lantau Hospital
Dr David Sun

Chief of Service (Anaesthesia & Intensive Care), Tuen Mun Hospital/Pok Oi Hospital
Dr Lam Kwok-key

Executive Partner (Quality & Safety), Kowloon West Cluster/Associate Consultant (Medicine and Geriatrics), Princess Margaret Hospital
Dr William Lee

Department Operations Manager (Operating Suite), Alice Ho Miu Ling Nethersole Hospital
Ms Kwan Shuk-yi

Manager (Patient Safety and Risk Management), Quality and Safety Division, Hospital Authority Head Office
Ms Katherine Pang



Published on: 2017-09-08

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