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Hong Kong : Princess Margaret Hospital announces root cause analysis investigation on sentinel event.

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.

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Publication:Mena Report
Date:Sep 9, 2017
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