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ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS
(1 October 2012 – 30 September 2013)

ANNUAL REPORT ON
SENTINEL AND SERIOUS UNTOWARD EVENTS
1 October 2012 – 30 September 2013

HOSPITAL AUTHORITY
HONG KONG

1

ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS
(1 October 2012 – 30 September 2013)

ACKNOWLEDGEMENT

This is the sixth Annual Report on Sentinel and Serious Untoward Events. By continuously learning from sentinel and serious untoward events and by building safe systems, processes and practices to mitigate the recurrence of such events, it demonstrates the Hospital Authority’s commitment to quality and patient safety.

We would like to take this opportunity to acknowledge all frontline staff, nurses, clinicians, risk managers and executives for their immense dedication and support in improving patient safety in recent years.

Without their invaluable and incessant

efforts in planning and executing various improvement initiatives to enhance patient safety through risk identification and mitigation, the publication of this annual report would not have been as meaningful.

Patient Safety and Risk Management Department
Quality and Safety Division

2

ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS
(1 October 2012 – 30 September 2013)

TABLE OF CONTENTS

Executive Summary

4

CHAPTER 1 – Introduction

9

CHAPTER 2 – Sentinel and Serious Untoward Event Policy

11

CHAPTER 3 – Sentinel Events Reported from 1 October 2012 to 30 September 2013

13

CHAPTER 4 – Serious Untoward Events Reported from 1 October 2012 to 30 September 2013

21

CHAPTER 5 – Actions Taken and Discussion

26

CHAPTER 6 – Conclusion

42

CHAPTER 7 – The Way Forward

44

Annex I:
Annex II:

HA Sentinel and Serious Untoward Event Policy
Summary of Individual Sentinel Events and Recommendations for
Improvement

3

ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS
(1 October

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