The Hospital Authority (HA) released the 46th issue of “HA Risk Alert” on 28 July. According to the report, there were two sentinel events in the first quarter of 2017 (January – March).


"Subsequent to incident review and analysis of root causes of these incidents, important lessons of patient safety are identified, while recommendations are made and shared in this publication to avoid similar events in future," the HA spokesperson said.

Exploring the feasibility of uploading source images to CMS for pre-operative checking

One of the events involved a neurosurgeon at Queen Elizabeth Hospital (QEH) performing an operation on the wrong side of a 54-year-old woman’s skull. Fortunately, despite the errors, the patient has made good recovery after the operation.

The Root Cause Analysis (RCA) panel looked into the incident and explained the team had made their best efforts in arranging radiological investigation for the patient in an emergency situation, and in making a timely diagnosis and treatment plan. Additionally, the team had followed the standard protocols to perform a “time-out” procedure, including checking of patient identity, surgical site and adverse drug reactions etc., before the operation.

However, since the patient was in critical condition due to subarachnoid haemorrhage and hydrocephalus, the team decided to arrange an urgent craniotomy before the radiological images were uploaded to Clinical Management System (CMS). Based on recollection of preliminary computed tomography (CT) angiogram images, the neurosurgeon perceived that the aneurysm was located in the patient’s left side of the brain.

The team decided to arrange an urgent craniotomy before the radiological images were uploaded to CMS.
The team decided to arrange an urgent craniotomy before the radiological images were uploaded to CMS.

It was until during the operation when the neurosurgeon realised the aneurysm was indeed located at right side of the patient’s brain. The neurosurgeon then placed back the bone flap on the left side, and proceeded to perform right craniotomy after disclosing to the patient’s family.

In response to this incident, the RCA panel recommended exploring the feasibility of uploading source images to CMS as soon as possible for pre-operative checking. They also advised to review and revise the management protocols and checklists for surgical safety to include marking of surgical site and checking of radiological images during the “time-out” procedure, and to see if a second “time-out” procedure is possible to be conducted before the skin incision. The panel also suggested reinforcing the practice of having surgeons, anaesthetists and nurses to sign on the Surgical Safety Checklist.

Perform radiological imaging when completeness of the used suture anchor is in doubt

Another sentinel event found a broken metallic wire in a patient’s glenoid cavity. The patient was admitted for right shoulder arthroscopic repair surgery. Four suture anchors were used during the operation.

The operation was uneventful, except the surgeon found difficulties when retrieving one suture introducer during the operation. It was until 6 weeks later when a follow up X-ray revealed a 14mm x 1mm broken metallic wire in the patient’s right glenoid cavity, which was likely to be the broken part of the metallic introducer of the suture anchor. The metal wire was retrieved in a subsequent operation successfully.

When completeness of the used suture anchor is in doubt, surgical teams should perform radiological imaging to confirm.
When completeness of the used suture anchor is in doubt, surgical teams should perform radiological imaging to confirm.

The surgical team was said to be unfamiliar with the newly introduced suture anchor device. They were unaware of possible broken suture anchor fragment when encountering difficulties in retrieving the introducer.

To avoid this from happening in the future, the panel recommended all stakeholders to be alerted on the risk of used instrument. Communication among clinical team members should be improved to acquaint with the design and functional features of the suture anchor device before operation.

The panel specifically emphasised surgical teams should check for completeness of instrument/material upon removal. When completeness of the used suture anchor is in doubt, surgical teams should perform radiological imaging to confirm. Any surgical instrument/material should be documented in details. MIMS

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