Hospital Authority announces initial findings of surgical light falling incident (with photos)

The following is issued on behalf of the Hospital Authority:

     The Hospital Authority (HA) spokesman announced the initial findings of a surgical light falling incident today (February 24):
 
     The HA has completed inspection on all public hospitals with surgical light facilities, with a total of 471 surgical lights. It is confirmed that most of them are up to safety standards and can continue to be used, yet the screws of 23 surgical lights may be at risk and they have been suspended for use immediately. Eleven of them have been repaired and the remaining surgical lights will be fixed in the short term. Moreover, for the sake of prudence, the HA has additionally inspected 482 medical pendants in public hospitals and they are all confirmed to be safe for use.
 
     The HA Director (Quality and Safety), Dr Michael Wong, said, "The HA is extremely dissatisfied with the vendor's performance, and has ordered them to solve the problem appropriately and submit a thorough report. The HA will stringently follow up the incident, and reserve the rights to pursue relevant responsibilities. Also, the HA has reported the incident to relevant government regulatory bodies. If there are any irregularities found in the investigation, the HA will consider referring the case to law enforcement agencies for follow-up.
 
     "The safety of patients and staff is our utmost concern. The HA has zero tolerance for any risks. All operation rooms have to be safe. Surgical lights that may be at risks are all suspended for use. Patients and staff can rest assured that the operation rooms, which maintain normal service now, have been confirmed to be safe."
 
     After the surgical light falling incident in United Christian Hospital, the HA immediately entrusted an independent expert advisor, Dr Eric Lim, to conduct an in-depth investigation on the cause of the incident. Dr Lim said, "According to the initial investigation, the six screws, which are for fixation, in the main post of the concerned surgical light are all broken. At least four of the screws show signs of metal fatigue. Rusted stain can be found on some of them as well. It is reckoned that metal fatigue of the screws is not formed in a short period of time. Eventually, the screws cannot hold the weight of the surgical lights, causing the lights to fall on the ground."
 
     Dr Lim makes a few recommendations on the maintenance of surgical lights:
 

1. Maintenance and repair must be done by trained and certified technicians;
2. Tools with a correct torque should be used during maintenance, so as to ensure that the screws can withstand a normal amount of torque;
3. If loosened or broken screws are found, replacement should be done by a certified technician, and the vendor should be requested to conduct an investigation; and
4. Screws should be replaced by new ones from time to time.

 
     To ensure the safety of patients and staff, the HA has followed the initial findings concluded by Dr Lim and ordered the vendor to replace the screws in other surgical lights concerned with new ones. Before all replacement of screws is done, the vendor should increase the frequency of surgical light check-ups to once per one to two weeks.
 
     The HA expresses its gratitude to Dr Lim for his root cause analysis and recommendations. The HA will request the vendor to stringently follow up and implement the recommendations concerned, so as to ensure the safety of patients and staff.
 
     In the past few days, elective operations of 141 patients have to be rescheduled and all of them have been rearranged, so that the operations can be carried out as soon as possible.