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Prince of Wales Hospital Releases Investigation Panel Findings on a Medication Incident

The Prince of Wales Hospital today (22 September 2011) released the investigation findings of a drug prescription incident on 9 July 2011 involving a 73-year-old female patient.

The Investigation Panel has found that insufficient communication between the duty resident doctor and the house officer and the fact that the house officer had not checked patient’s identity had led to the duplicated prescriptions, which caused the patient’s condition to deteriorate. The patient had subsequently died. The Hospital expresses her deep condolences and apology to the patient’s family. The Hospital would assume responsibility for this unfortunate incident and would keep close contact with the family.

According to the investigation report, the patient had a history of diabetes mellitus, hypertension, aortic stenosis, heart disease, chronic renal failure and anaemia. She attended the Accident and Emergency Department on the night of 8 July 2011 due to shortness of breath and bilateral leg oedema and was transferred to the medical ward early next morning (9 July). The admission resident doctor assessed the patient and wrote “resume usual med, stop Zocor, lasix to IV” on the patient’s medical notes. The resident transcribed the patient’s usual medications, including Aspirin, Calcium carbonate, Lasix and Pantoloc directly onto the patient’s Medication Administration Record (MAR). He then asked a house officer to follow up on the management.

The Panel found that the house officer read the notes and perceived the instruction was for her to resume the patient’s usual medications in addition to those already prescribed on the MAR. She transcribed the medications listed on a print-out from the Electronic Patient Record onto the MAR. The print-out actually belonged to another patient admitted earlier. The medications included Candesartan, Gliclazide, Metformin, Betaloc and Isordil.

The medications were administered to the patient during the morning medication round at around 7:30am. The transcription error was detected during the doctors’ round at around 10:30am. The administration instruction was adjusted immediately. The patient was put under close observation. The patient was found hypotensive at around 11:00am and intravenous inotropic drugs were given. She was transferred to the High Dependency Unit for close monitoring and treatment. Her blood pressure quickly returned to the level on her admission. But she remained in critical condition and passed away two days later.

The Panel has identified the root causes of the incident as follows:
1. Communication breakdown: The admission resident documented his prescription plan and completed the transcription of the medications onto the MAR as well. But the house officer misinterpreted his notes as an instruction, resulting in duplicated transcription unnecessarily.
2. Lack of a standard practice in handling print-outs from the Electronic Patient Record: The print-out belonging to another patient admitted earlier was not properly filed or handled. It was left unattended on the doctors’ station and mistaken as belonging to the index patient.
3. Non-compliance with the guidelines of checking patient’s identity: The house officer had not checked the patient’s identity on the print-out before transcribing.

The Panel made the following recommendations:
1. To improve the documentation of patient’s care by clearly stating what actions have been done and what needs to be done.
2. To standardize the handling and filing procedures of print-outs from the Electronic Patient Record.

The Hospital has accepted the report from the Investigation Panel and would follow up on the recommendations. The Hospital has also met the deceased’s family to explain the details of the report and expressed condolences again. The case has been reported to the Coroner. Assistance would be provided to facilitate the Coroner’s investigation.

The Hospital has notified the medical school of the report findings. Follow-up actions will be taken according to established human resources procedures.

The Hospital is deeply grateful to the Chairman and members of the Investigation Panel for their work in completing the report. Dr So Hing-yu, Cluster Coordinator (Quality and Safety), New Territories East Cluster served as the Chairman of the investigation panel. Other members included:
- Mr Peter Mok, Member, Hospital Governing Committee, Prince of Wales Hospital
- Dr Li Chi-kong, Coordinator (Clinical Services), Prince of Wales Hospital
- Dr Jonas Yeung, Consultant (Medicine), Alice Ho Miu Ling Nethersole Hospital
- Dr Law Chun-bong, Representative, Central Coordinating Committee (Medicine), Hospital
- Authority
- Dr Adrian Tse, Representative, Quality and Safety Division, Hospital Authority