The Princess Margaret Hospital (PMH) reported a sentinel event to the Hospital Authority Head Office (HAHO) on 14 July after a doctor performed an operation on the wrong side of an 86-year-old man’s skull.

The incident came after another brain surgery blunder four months ago when a neurosurgeon at Queen Elizabeth Hospital (QEH) also performed surgery on the wrong side of the brain.

Following the incident, the Hospital Authority (HA) has issued an internal reminder to highlight the importance of carrying out time-out procedures in accordance with the Surgical Safety Checklist.

Two brain surgery blunders in four months

In the latest incident, the elderly male patient was admitted to the neurosurgery ward at PMH on 12 July due to a subdural hematoma (SDH). An emergency burr hole operation was then arranged on the left side of his skull to remove the blood clots.

It was until when the doctor observed minimal blood clot after opening of the dura that he/she realised the drilling was carried out on the right side. After closing the wound on the wrong side, the doctor proceeded to drain the blood clots on the left side of the brain.

The patient regained consciousness after the surgery and has been in a stable condition. PMH has fully informed the incident to the patient’s family and extended an apology.

The incident has also been reported to the HAHO on the same day of the operation. A Root Cause Analysis (RCA) Panel will be formed to initiate an investigation into this surgery blunder.

Four months ago, a neurosurgeon at QEH mistakenly performed a surgery on the wrong side of the brain for a patient who suffered from an aneurysm that caused an increase in intracranial pressure. The investigation report revealed the doctor had not marked the position to be drilled on the patient’s skull, and he/she only relied on his/her own memories of preliminary computed tomography (CT) angiogram images to carry out the operation.

The importance of time-out procedures in accordance with the Surgical Safety Checklist

According to HA, a corporate-wide Surgical Safety Policy is currently under review to enhance the effectiveness of surgical team’s time-out procedures, which was initiated by the Department of Surgery at Prince of Wales Hospital (PWH) in January, 2008.

Surgical Safety Checklist reinforces the goal to uphold safety of a surgery. The checklist allows the surgical teams to double-check patients’ details such as their identities, known allergies, and making sure operations are carried out on correct surgical sites.

A study published in the New England Journal of Medicine has demonstrated significant reductions in both mortality and complication rates by introducing a Surgical Safety Checklist. In the study, the rate of any complication at all sites dropped from 11.0% at baseline to 7.0% after introduction of the checklist. The total in-hospital rate of death has also dropped from 1.5% to 0.8%. MIMS

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Sources:
http://www.hkorn.org.hk/PnSM_1015-3-Implementation-%20checklist%20in%20th%20eyes%20of%20surgeons.pdf
http://www3.ha.org.hk/haconvention/hac2010/proceedings/pdf/Service/spp1-6-wong.pdf
http://www.info.gov.hk/gia/general/201707/14/P2017071400624.htm
https://www.hk01.com/港聞/104901/公院4個月2宗開錯腦醫療事故-瑪嘉烈醫生搞錯左右腦-病人捱多刀
http://www.scmp.com/news/hong-kong/health-environment/article/2102705/hong-kong-brain-surgeon-drills-hole-wrong-side