The Hospital Authority (HA) said on Wednesday that it has set up a committee to look into recent cases of X-ray assessment lapses of staff at some of the city’s public hospitals.
The panel will investigate the cases where hospital staff failed to read X-rays properly or were careless in their conclusions in relation to X-ray findings, it said.
After reviewing the cases, the panel will recommend measures for work improvement in the healthcare workers to “ensure that they can identify abnormalities in chest X-ray findings in a more timely manner,” the HA said.
In a press release, the agency said it decided to set up the investigative panel as there had been three incidents recently where hospital workers had failed to read X-rays properly or were guilty of oversight in writing down the findings.
Such lapses can mean the patients not getting the required or correct medical care for their health problems.
The HA’s Quality and Safety Department took the initiative to establish a “Root Cause Analysis (RCA) Panel” at the Head Office level because of the coincidence in reporting time and similarities in the nature of the incidents, according to the statement.
The panel will examine the three incidents so as to explore means and ways to prevent improper work by the hospital staff.
The RCA Panel will be joined by representatives from Central Coordinating Committees of respective specialties, with a report scheduled to be completed and disclosed in eight weeks, said the HA, which stressed that it attaches great importance to the quality and safety of patient services and that it has grave concern over the irregularities.
Unveiling the three incidents, all which involved missed shadows on initial X-rays for three patients, the HA noted that the three hospitals were Queen Mary Hospital, Prince of Wales Hospital and Princess Margaret Hospital, the Hong Kong Economic Journal reports.
In one of the incidents, a patient sought medical treatment at Ruttonjee Hospital in October this year due to epigastric discomfort. A chest X-ray was performed and the report showed a mass suspected to be malignant.
For further assessment, the patient was referred to Grantham Hospital, whose the Tuberculosis and Chest Medicine Unit found that Queen Mary Hospital, which had taken X-rays for the patients since 2016, had not detected the mass for three times.
Another incident involved a patient who had been admitted to the surgical ward of Prince of Wales Hospital through Accident & Emergency Department (AED) in November this year. As a chest X-ray discovered an opacity over the left upper zone of the lung, it was found that the patient had in fact taken a similar examination at the hospital in March last year and the X-ray film at that time also showed a shadow on the left lung. That meant that treatment had been delayed for more than one and a half a year.
As for the third one, a patient who attended the AED of Princess Margaret Hospital this month due to a fall accident was confirmed to have contracted lung cancer. Upon reviewing the patient’s chest X-rays taken in February 2017 and May 2018, it was found that a shadow in the right lung was unnoticed on both occasions.
The HA said the three hospitals will continue to offer follow-up treatment according to the patients’ clinical condition and give assistance as necessary to the patients and their families.
The hospitals involved have offered apologies to the patients and their families, the HA said, while reminding front-line health workers to be cautious in reviewing patients’ examination findings to ensure timely diagnosis and treatment.
Dr. Anthony Ying Chi-ho, a specialist in clinical oncology, told HKEJ a delay in treatment seen in the three incidents was extremely non-ideal since it takes only two to three years before lung cancer can deteriorate from the first stage to the third or the fourth.
Ying pointed out that since X-ray films taken by a public hospital are rarely examined just by one healthcare staffer but by several, the incidents that took place in the three hospitals suggested something had gone wrong, as more than one staffer had overlooked the cases.
The HA needs to conduct thorough reviews and investigations, the doctor said.
Civic Party legislator Dr. Kwok Ka-ki, who is a medical doctor, suspected that the hospital staff involved in the three incidents might be doctors at the junior rank who are inexperienced and therefore missed what they should have noticed.
Tim Pang Hung-cheong, community organizer for the Society for Community Organization, believed the incidents, on top of the two similar ones seen in July and September at Kwong Wah Hospital and Tseung Kwan O Hospital, respectively, were all evidence that this is not an individual incident but a problem in the entire healthcare system.
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