Caritas Medical Centre announces sentinel event
The following is issued on behalf of the Hospital Authority:
The spokesperson for Caritas Medical Centre (CMC) announced a sentinel event today (June 27):
A 48-year-old female patient with good past health was admitted to the hospital's surgical ward on June 17 for abdominal pain. The patient underwent an abdominal computed tomography (CT) with contrast on June 18 which indicated early appendicitis, mild colitis and a small paratubal cyst on the right side.
On the same night, the patient was arranged for an emergent minimally invasive laparoscopic appendectomy operated by a higher surgical trainee. During the operation, oozing from the surgical site was noted, and the small paratubal cyst was torn during the procedure. The on-call Associate Consultant was called in. The Associate Consultant arrived and consulted the Obstetrics and Gynaecology team at Princess Margaret Hospital, where it was confirmed that a cystectomy was not required as the bleeding had stopped. The patient remained in stable condition after the operation and continued to receive close observation and treatment. The excised tissue was sent to the pathology department for examination.
On the afternoon of June 23, the patient developed a low-grade fever with increasing abdominal pain and afterwards underwent an abdominal CT scan with contrast again. The report revealed the appendix remained intact and the pathology report, which was available in the late evening of June 25, showed that the excised tissue was a fallopian tube instead of the appendix.
The hospital is very concerned about the incident and met with the patient and her family on the following morning (June 26) to explain the details of the incident and to offer their sincerest apologies. Subsequently, the patient underwent an operation to have the inflamed appendix removed. The operation was uneventful. The hospital will continue to closely monitor her post-operative recovery.
The preliminary investigation suggests the doctor involved mistook the fallopian tube for the appendix due to tissue adhesion near the surgical site.
The CMC once again extended sincere apologies to the patient, and has requested the Department of Surgery to review the arrangements and handling of laparoscopic surgeries, including staffing deployment, task assignment, supervision and coaching. Training for frontline healthcare staff will also be strengthened to ensure proper management of every procedure-related detail to safeguard patient safety.
The incident has been reported to the Hospital Authority Head Office via the Advance Incident Reporting System. A root cause analysis panel will be formed to investigate the incident thoroughly. The investigation and recommended improvement measures will be completed within eight weeks.
The Root Cause Analysis Panel members are as follows:
Chairperson
Dr Sara Ho
Service Director (Quality and Safety), Hong Kong East Cluster
Members
Dr Raymond Cheung
Chief Manager (Patient Safety and Risk Management), Hospital Authority
Dr Lai Tak-wing
Clinical Stream Coordinator (Surgery), Kowloon West Cluster
Dr Sunny Cheung
Chief of Service (Surgery), North District Hospital
Mr Bill Wang
Vice Chair, Hong Kong Kidney Foundation
Member & Past Chair, Patient Liaison Advisory Group of International Society of Nephrology
