For discussion
on 14.9.1998
LegCo Panel on Health Services
Meeting to be held on 14 September 1998
Medical Incidents : Background and measures taken in
prevention and minimization in public hospitals
Introduction
This paper sets out the measures adopted in public hospitals to prevent and minimize the occurrence of medical incidents.
Factors contributing to medical incidents
2. There are various factors that contribute to or are of relevance to medical incidents. Remedial measures targeting at these factors have been adopted in public hospitals to prevent or minimize medical incidents. Such factors include:
- Severity/ natural course of illness
It is not uncommon as part of the natural course or development of certain medical illness for adverse life threatening events to be manifested. Such events may be misconstrued by patients as medical incidents. For instance, a patient suffering from a heart attack while under the care of a medical practitioner could die suddenly, with an abnormality of heart rhythm as a direct consequence of the illness.
- Intrinsic risks of medical treatment, investigations and procedures
Many medical interventions are associated with intrinsic risks. Decisions on medical intervention are usually made based on judicious professional evaluation of the trade-offs between the benefits and potential risks that may result from the intervention. For example, chemotherpeutic drugs given to cancer patients are known to be toxic and may be life threatening. A proportion of patients will benefit from the treatment leading to a cure or prolongation of life. However, a small number may succumb to the toxic effects of the drugs.
- Known complications arising from medical treatment and procedures
Most medical treatment, investigations and procedures carry both benefits and risks. Measures are usually taken to minimize the risks recognised. However, in most instances, a residual unpreventable risk remains. For example, it is well known that liver biopsies for the diagnosis of liver pathology are associated with the risk of bleeding (the bleeding rate is 0.15%). Surgical intervention may be required to manage such known risk when it occurs. While the complication rate of liver biopsies is low in well managed units, there is still a residual risk of complications.
- Instrument and mechanical failure
Some medical incidents can be attributed to instrument and mechanical failure. For example, fracture of artificial heart valves due to imperfection in the manufacturing process could give rise to life threatening consequences years later.
- System malfunction and disorganisation of services and care
A system malfunction, especially when that occurs in essential life maintaining systems, may contribute to medical incidents. Disorganisation of services and care particularly in complex situations is also a source of errors and medical incidents.
- Human errors
Medical incidents may be attributable to human errors, which are mostly unintended, resulting from aberrations in mental functioning. A minority of cases are due to negligence or carelessness. However, not all such errors can be totally eliminated. An introduction of system safeguards and risk management initiatives could reduce or minimise unintended human errors.
- Psycho-social factors
The sudden loss of a loved one may generate grief reactions such as denial, anger or depression. The sense of anger may become so intense that the healthcare providers may become the target of blame. The bereaved may have an exceptionally strong interest to understand every detail of the events that led to the death. This overwhelming need may further create misunderstandings between the healthcare providers and the bereaved.
- Communication problem
Some medical incidents may be attributed to communication problem between the care givers and the patients or relatives. Such problem may arise due to inadequate explanation on the risks and benefits of the medical intervention or the patients' medical conditions; ineffective communication on the part of carers; and difficulty of the patients and relatives to understand, appreciate or accept the information given by healthcare providers.
Remedial Measures
3.In order to prevent or minimize medical incidents from occurring in public hospitals, the Hospital Authority (HA) has adopted and enhanced the following key accountability and quality assurance systems and structures -
- Professional competence and clinical supervision
Professional competence is the key to avoiding medical incidents. HA has been recruiting clinical staff with appropriate professional and specialist qualifications, knowledge and skills to ensure professional competence. This is further enhanced through extensive programmes of postgraduate education and continuing staff training and development. There is a well-developed and structured system in place whereby the work of junior clinical staff is supervised by qualified senior clinicians during daytime and off-hours.
- Clinical audit and quality assurance systems
Clinical audit is well recognised as an important professional accountability mechanism to ensure professional performance and standards in the healthcare setting. It is a systematic and critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, the resulting outcome and quality of life for the patient.
Clinical audit and quality assurance systems have been established in clinical departments of all HA hospitals to maintain high professional standards and accountability. At the hospital level, there is a structured clinical audit mechanism for each Clinical Management Team to develop, implement and evaluate clinical protocols and treatment guidelines through the process of clinical audit activities. A central Clinical Audit Committee in each hospital is responsible for facilitating, co-ordinating and monitoring activities amongst various clinical units.
At the Head Office level, a HA Clinical Audit Committee has been established to define parameters, co-ordinate territory-wide activities, monitor progress of hospitals, and co-ordinate experience-sharing sessions on clinical audit. A set of draft guidelines on clinical audit has been issued to hospitals to provide guidance to clinical staff.
- Risk management initiatives
The application of risk management aims to prevent, reduce and contain risks in the health care setting. Effective risk management can ensure safer practices, safer systems of work, safer premises and greater awareness of danger and liability, hence resulting in greater patient safety and improved staff morale.
HA has progressively introduced risk management concepts and practices into all HA hospitals and the HA annual planning process. Various risk management initiatives have been prioritized and implemented to prevent and minimize the occurrence of medical incidents. These initiatives include implementation of the Medication Incident Reporting System; development of an automated unit dosing and drug labelling system; standardisation of triage guidelines for Accident & Emergency Departments; infection control procedures; introduction of occupational and health risk standards; and improvements to the hospital security system, etc.
The Risk Management Steering Group at the HA Head Office has established a comprehensive checklist of all risk areas for use by hospitals and individual departments as a scanning tool for risk identification. A set of hospital contingency plans to deal with internal disasters, such as utilities failure, fire and flooding, has also been formulated and distributed to hospitals. At the hospital level, Risk Committees, which comprise senior hospital management staff from various departments, have been set up to co-ordinate and monitor all risk management activities in each individual hospital.
- Complaint management system
There are established channels whereby patients, their families and the public can raise concerns, lodge complaints, air grievances and make suggestions on patient care and hospital services. Designated officers are responsible for dealing with public complaints at both the HA Head Office and hospitals. Appeal cases are reported to the Public Complaints Committee which consists of members of the HA Board and the public to ensure that all complaints are properly handled.
Following a critical evaluation in late 1997 on the management of public complaints, HA has enhanced internal mechanisms in hospitals to ensure that all complaints and concerns raised by patients and their relatives are promptly and effectively investigated and brought to the attention of the senior hospital management. Hospitals have designated a senior nurse to act as patient advocate to oversee the patient relations function. Communication skills training are provided for frontline staff and clinicians to enhance client service and to reduce conflicts arising from miscommunication. HA has reviewed the terms of reference of the independent Public Complaints Committee and expanded its role in monitoring the handling of complaints by hospitals and to cover complaints of clinical (in addition to administrative) nature. The complaint investigation findings will help identify problems or risks in clinical care and the remedial measures required.
Advice sought
4. Members are invited to note the remedial measures adopted by HA as set out in paragraph 3 above.
Health and Welfare Bureau
September 1998
