A doctor carried out tissue biopsy on the wrong side of a brain stem death patient, the Hospital Authority (HA) announced on September 29.
The patient was admitted to the Accident and Emergency Department of Caritas Medical Centre (CMC) on September 12 due to intracranial haemorrhage. Three days later, brain stem death was confirmed.
As the deceased's family gave consent to donate the deceased's liver to a patient in need of a transplant, a hospital with potential organ recipients was informed. An earlier computed tomography (CT) image of the patient concerned showed a 2-centimetre suspected lesion at the right side of the base of the skull bone. Despite the absence of radiological features suggestive of an aggressive nature of the suspected lesion, the medical team prudently decided to take a nasal biopsy to exclude the possible chance of malignancy.
Upon receipt of notification in the evening of September 15, an Ear-Nose-Throat (ENT) surgeon of the Kowloon West Cluster ENT team who was based in Yan Chai Hospital was called upon to conduct the biopsy of the skull base tissue in CMC before functional deterioration of the donor's major organs.
After packing the specialised equipment in YCH, the surgeon rushed to the operating theatre at CMC where another special team was harvesting the liver. To avoid facial disfigurement of the patient, the doctor chose a technically more difficult approach using an endoscope to access the deep-seated skull base through the nasal cavity. The real-time frozen-section tissue examined by the pathologist did not show malignancy. Concurrently, transplantation was conducted the next day in Queen Mary Hospital (QMH).
Four days after the transplantation, during the routine collation of post-transplantation investigation records, the Organ Donation Coordinator found in the pathology biopsy reports that the tissue was taken from the left side instead of the right side revealed in the CT image. Subsequent confirmation with involved teams by the ENT team affirmed that the tissue had been mistakenly taken from the left side.
To ensure appropriate follow-up treatment for the organ recipient, the clinical team agreed to the need to seek the consent of the donor's family for conducting a further biopsy. Fortunately, the pathological diagnosis on September 29 revealed no malignancy for the tissue taken.
QMH was informed of the pathological result of the further biopsy and disclosed the incident in detail to the organ recipient.
While this incident of wrong-side procedure did not cause any direct detrimental effect to the treatment of the patient being operated on, such an incident could affect the treatment of another patient.
The HA and the hospitals concerned have agreed to classify the incident as a sentinel event. Accordingly, a Root Cause Analysis Panel will be established to investigate the event for lessons to be learned and to work out recommendations to prevent recurrence of similar incidents. MIMS
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