In January and February this year, two renal specialists at the United Christian Hospital (UCH) failed to arrange an anti-viral drug for a renal patient, also a hepatitis B carrier, when they prescribed the patient with a high dosage steroid. The patient, Kwai-sze Tang, later suffered from acute liver failure, and she is now in critical condition at Queen Mary Hospital (QMH) after undergoing two liver transplants.

In May, the Hospital Authority (HA) established the Root Cause Analysis (RCA) panel to investigate the reasons behind this medical blunder. The panel submitted their report to HA yesterday, and revealed their findings and recommendations during a press conference.

“High degree of vigilance is especially critical in the face of a heavy workload”

In response to a question of whether the manpower shortage is the root cause of this medical blunder, Professor Daniel Tak-Mao Chan, chair professor in the medicine department at the University of Hong Kong (HKU), denied the saying.

“The main reason for this incident is an insufficient level of vigilance. A high degree of vigilance is especially critical in the face of a heavy workload. The workload of internal medicine has always been heavy. It has been increasing for many years since we are facing an ageing population with a growing complexity of diseases. However, even under this situation, we should remind ourselves of always maintaining a high level of vigilance,” Chan remarked.

“We cannot ascribe doctors’ workload as the root cause of this incident. Nevertheless, the heavy workload is an important contributing factor. Without resolving this manpower shortage, the situation will remain very risky.”

According to the panel, both doctors were aware of Tang as a hepatitis B carrier.

“The doctors have seen the automatic reminder in the computer system that warned them of the risk. They have also put hepatitis B in Tang’s medical record. When treating other hepatitis B carriers, they have prescribed patients with anti-viral drugs,” Chan explained. “We believe they might have wanted to handle the heavy patient load as soon as possible and had neglected the important information,” he concluded.

Asked if the team would consider adding additional reminders in the computer system, Clinical Stream Coordinator (Medicine) of Kowloon East Cluster Dr Ip-Tim Lau revealed that they will review the system on a regular basis – but he remarked that adding excessive reminders in the system might lower doctors’ vigilance and render the system inefficient.

Poor communication led to delay in announcing the medical blunder to the public

The panel also dismissed the rumours that the hospital had intentionally ‘covered up’ the blunder. Instead, staff’s lack of experience in handling medical blunder and their over-reliance on their seniors to handle situations were quoted as the reasons leading to the delay.

“With regards to the communication, we would like to emphasise the communication between UCH and the liver transplant team at QMH was satisfactory. However, within the various teams at UCH, we recommended the hospital management to look into the current clinical governance system with an objective to improve the communication among different teams,” advised Chan.

“Patients may suffer different diseases and they fall under different specialties. Therefore, it is reasonable that all of these doctors should be actively involved in managing the condition of the patients. Otherwise, there will be too many people making decisions without communicating with each other.”

Although Tang was admitted UCH on 1 April 2017, the internal medicine and geriatric teams that were in charge of taking care of Tang did not inform the renal team in a timely manner. It was not until 5 April when Tang was transferred to QMH that the two renal specialists were aware of the situation. Fifteen days later, Dr Tak-Yi Chui, chief executive of UCH, was finally informed of the blunder and reported the incident to HA.

Dr Tak-Yi Chui, chief executive of UCH, apologising to the UCH patient and her family. Photo credit: HK01
Dr Tak-Yi Chui, chief executive of UCH, apologising to the UCH patient and her family. Photo credit: HK01

“Both UCH and QMH bear the responsibility to report any Sentinel and Serious Untoward Events. However, the management at these two hospitals has not strictly followed the procedures,” said Dr Shao-Haei Liu, HA’s Deputising Director (Quality & Safety).

Panel: “No further comment” – on referring the case for a hearing with the Hong Kong Medical Council (HKMC)

The panel refused to comment if the two doctors would be suspended from their duties or punished by the hospital. Liu emphasised the primary mission of the panel was to find out the root cause of the incident, and UCH will handle the personnel management with a separate mechanism.

Meanwhile, HA has accepted the investigation report. "Specific recommendations will also be taken forward at the HA Head Office (HAHO) level for corporate-wide implementation such as exploring measures to highlight the risk related to the administration of high-dose immunosuppressive medications in treatment guidelines and using information technology solutions," remarked Dr Pak-YinLeung, HA Chief Executive.

Secretary of Food and Health Professor Sophia Siu-Chee Chan also welcomed the report and emphasised HA will take follow-up actions should punishments for the aforementioned doctors are deemed necessary.

However, not all are satisfied with the report. Legislative Councilor Dr Ka-Ki Kwok expressed his disappointment towards the investigation. He has accused the senior management of HA and UCH of shirking their responsibilities. With years of experience, he questioned why the doctors would underestimate the severity of the incident and neglect the necessary procedures to report to the authority. He further emphasised that the doctors should shoulder the responsibility of this medical blunder. Otherwise, the public may lose faith towards HA, or even the organ donation scheme for future transplants.

Meanwhile, Dr Seamus Yuk-leung, Vice-Chairman of Frontline Doctors' Union, said the report is unfair to doctors on the front line – as it had failed to highlight the insufficient support provided by the management. He suggested that HA to establish appropriate time limit for doctors to handle patients of complicated conditions. MIMS

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