A few days ago, a medical risk warning incident occurred at Pok Oi Hospital in Hong Kong, which attracted widespread attention. On May 10, the hospital released a root cause analysis report on the medical risk warning incident, detailing the incident, its causes, and subsequent i

A few days ago, a medical risk warning incident occurred at Pok Oi Hospital in Hong Kong, which attracted widespread attention.

html On May 10, the hospital released a root cause analysis report on the medical risk warning incident, detailing the incident, causes and subsequent improvement suggestions. The

report shows that a female patient had vaginal bleeding after menopause and underwent a uterine biopsy at the hospital on January 5, 2024. The test results showed that she had endometrial cancer.

Picture source: Screenshot of the official website of Hong Kong Pok Oi Hospital

The patient underwent surgery at Tuen Mun Hospital on February 26 to remove the uterus, fallopian tubes, ovaries and pelvic lymphoid tissue.

The hospital subsequently conducted pathological tests on the uterine tissue removed from the patient after surgery and found that there were no cancer cells in the tissue samples. After the hospital re-examined the laboratory samples and conducted genetic testing, it was found that the biopsy sample taken by the patient on January 5 was mixed with biopsy cells from another patient diagnosed with cancer, causing deviations in the laboratory results.

After investigation, the Root Cause Analysis Committee confirmed that when staff of the hospital were handling a sample of a cancer patient on the laboratory workbench, part of the cancer patient's fine sample tissue was spilled onto the next sample vessel (that is, the sample used by the patient in question). , leading to sample confounding. The

Committee believes that the location used to store unused sample vessels is connected to the workbench for processing samples. In addition, the sample vessels are placed with their openings facing upwards. The location of the equipment is not ideal and needs to be improved to reduce the risk of samples being processed. Risks of confounding. The

committee pointed out that the work guidelines require laboratories to check whether the sample vessels are clean before processing samples from different patients. Although the laboratory staff had suspected that the tissue volume of the sample in the vessel was different from the description in the record, because the sample was tiny and not very different from the description in the sample record, the staff continued the testing procedure without further follow-up.

In this regard, the committee made the following suggestions for improvements in this incident:

Cover the location where unused sample vessels are stored, and place the vessel openings upside down to reduce the risk of patient samples being mixed;

Strengthen laboratory staff's instructions on handling samples. Training and supervision, remind staff to carefully check the sample vessels used to ensure that they are clean and usable;

establish clear risk guidelines to properly handle laboratory risk events such as suspected sample mixing;

laboratory staff should strengthen communication and improve Be alert and seek professional advice from superiors if in doubt;

improve the department's existing measurement guidelines for fine samples and formulate more detailed unified descriptions of measurement units so that staff can more effectively identify the accuracy of sample volumes.

At present, Hong Kong Pok Oi Hospital has explained the investigation results to the patients and their families, and once again apologized for this incident. The hospital will also continue to follow up on the patient's clinical condition and follow up and implement relevant recommendations to prevent similar incidents from happening again.

Source: Guangzhou Daily