Caritas Medical Centre announces root cause analysis report of previous sentinel event
The following is issued on behalf of the Hospital Authority.
The spokesperson for Caritas Medical Centre (CMC) today (September 5) announced the root cause analysis report of a previous sentinel event:
A 48-year-old female patient underwent an emergency laparoscopic appendectomy on the night of June 18 due to early appendicitis.
The procedure was performed by a higher surgical trainee. During the operation, the surgeon identified a mildly inflamed tubular structure in the patient's abdominal cavity, believing it to be the inflamed appendix connecting to the perceived caecum. The excision of the inflamed tubular structure was performed. Oozing was noted at the surgical site afterward, and the ovarian cyst also ruptured with bleeding during the procedure. The on-call Associate Consultant was called in, and the on-call Obstetrics and Gynaecology team from Princess Margaret Hospital was consulted. It was eventually confirmed that the bleeding had been successfully stopped.
The patient underwent an abdominal CT scan with contrast again on June 25 due to a low-grade fever with increasing abdominal pain. The report revealed that the appendix remained in situ, while the pathology report also showed that the excised tissue was a fallopian tube. The patient was arranged for a laparoscopic appendectomy on the next day (June 26) and was subsequently discharged. The medical team will continue to follow up on subsequent treatment of the patient.
CMC announced the incident and formed a Root Cause Analysis Panel to analyse the incident. After the investigation, the Panel concluded that the root cause of the incident was that the assessment framework for the scope of clinical practice was unclear to accurately determine a trainee's competency of performing emergency surgery independently.
The Panel also noted that the surgeon lacked experience in performing an emergency laparoscopic appendectomy independently, which might have led to the difficulty in accurately identifying the location of appendix during the operation. In addition, the presence of an anatomical variation and intra-abdominal adhesion also increased the difficulty of the operation.
Regarding the incident, the Panel recommended strengthening the framework for defining trainees' scope of practice by referencing prevailing workplace-based assessment guidelines, which encompass supervision, coaching and evaluation.
CMC will follow up and implement the relevant recommendations. The hospital has met with the patient and her family to explain the findings of the report, and once again extended sincere apologies and expressed deep condolences to the patient. CMC will maintain communication with the patient and provide necessary assistance.
CMC has submitted the report to the Hospital Authority Head Office. The hospital also expressed gratitude to the panel. Membership of the panel is 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
Dr Symphorosa Chan
Cluster Coordinator (Obstetrics and Gynaecology), New Territories East Cluster
(Joined on June 30)
Mr Bill Wang
Vice Chair, Hong Kong Kidney Foundation
Member & Past Chair, Patient Liaison Advisory Group of International Society of Nephrology
Source: AI-found images
