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Announcement on a Medication Incident

The spokesperson of the Prince of Wales Hospital (PWH) made the following announcement today (13 July 2011) on a sentinel event:

A 73-year-old female patient attended the Accident and Emergency Department of the hospital on 8 July 2011 because of shortness of breath. She was subsequently admitted into the medical ward. The diagnosis was congestive heart failure. The patient had been suffering from various medical conditions which included heart disease, hypertension, aortic stenosis, anaemia, diabetes mellitus and chronic renal failure and had been receiving regular follow-up at the hospital’s medical specialist clinic. She had been on medications for her heart condition and on insulin for diabetes.

Upon admission, the resident doctor prescribed the patient with her usual medications as well as additional diuretics to relieve the heart failure condition. In the morning of 9 July during medical round, the on-duty doctor discovered that apart from the prescribed medications, five other medications including anti-hypertensive drugs (Betaloc and candesartan), coronary vasodilator (Isordil) and diabetes drugs (Diamicron and Metformin) were also included in the Medication Administration Record Form of the patient. These medications were not the usual ones taken by the patient. One dose of the additional medications was administered to the patient in the morning medication round at 7:30 am. The administration instruction was adjusted immediately.  The patient was put under close observation and her blood pressure was found to be low at 11:00 am.  Inotropics drugs were given and she was transferred to the High Dependency Unit for close monitoring and treatment.  Her condition remained critical but stable. The medical staff met the patient’s relatives to explain the situation.

The patient’s condition deteriorated on 11 July due to acute-on-chronic kidney failure. She finally succumbed at around 5:30 pm that day.

According to initial investigation, after the resident doctor prescribed the required medications on admission, the house officer may have mistakenly transcribed the five medications intended for another patient who was admitted in the same night onto the patient’s Medication Administration Record Form. The other patient had been given his prescribed medications and was not affected.

The hospital staff and the hospital management are deeply saddened by the incident. The hospital management has provided a preliminary explanation and expressed apology to the relatives, and also accepted the responsibility for this unfortunate incident.  The hospital would continue to keep in contact with the relatives to offer all possible assistance.

The incident has been reported to the Coroner’s Office and the hospital would assist in the Coroner’s investigation.

A report has been made to the Hospital Authority Head Office via the Advanced Incident Reporting System. An investigation panel will be set up to look into the incident and the investigation report is expected to be available and submitted to the Hospital Authority Head Office in eight weeks. The composition of the panel is as follows:

- Dr So Hing-yu, Cluster Coordinator (Quality and Safety), New Territories East Cluster

- 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