Tuen Mun Hospital announces a sentinel event

The following is issued on behalf of the Hospital Authority:

     The spokesperson for Tuen Mun Hospital (TMH) made the following announcement today (November 18) regarding a sentinel event:
     
     TMH received a request from the coroner in late October to provide a medical report on a patient who passed away at home on July 4.
     
     When compiling the medical report, the hospital confirmed that the 82-year-old male patient last visited TMH for follow-up consultation at the Specialist Out-patient Clinic of Medicine and Geriatrics on June 12. Upon reviewing the patient's blood test result that day, the doctor intended to lower the dosage of the anticoagulant, Warfarin, for the patient. A blood test was arranged for the patient in the following one to two weeks, which was around the end of June, to monitor the efficacy of the medication. The next consultation appointment had been scheduled on September 18.
     
     ‪However, according to the record in the Clinical Management System, the dosage of medicine prescribed to the patient was around two times of the intended dosage.
     
     TMH was very concerned about the incident upon knowing the dosage discrepancy issue when collating information of the deceased patient. The incident has been classified as a sentinel event and reported to the Hospital Authority Head Office (HAHO). A root cause analysis panel will be set up for in-depth investigation and to prevent the recurrence of similar incidents. A report will be submitted to the HAHO within eight weeks.

     TMH has met the family of the deceased this evening (November 18) to disclose the incident and expressed sincere apology and condolences. The hospital will fully cooperate with the coroner in the investigation.