In October, a public hospital in Hong Kong administered a sedative dose to a patient that was 10 times the prescribed amount. Tuen Mun Hospital reported that the patient had come to its accident and emergency department on October 18 and was transferred to the intensive care unit (ICU) for further treatment. Hospital authorities explained that sedation was administered to aid with medical procedures, but medical staff later found that the sedative dose injected was far higher than the intended prescription.

Despite this error, the patient showed no abnormal reactions and remained under close observation. The hospital reported that the patient's condition remained stable, and they were later transferred to a general ward. Due to privacy considerations, the hospital did not disclose the patient’s age or gender. Tuen Mun Hospital has since expressed deep concern about the mistake and has contacted the patient’s family to explain the situation and issue an apology.

Following the incident, the hospital reminded its staff to adhere to established dosage protocols and plans to review its emergency department's workflow to prevent similar errors. The Hospital Authority was informed of the event via an incident reporting system, and a committee has been formed to examine the cause and provide recommendations for improvement.

A hospital source confirmed that the drug involved was ketamine, a substance controlled under Hong Kong's Dangerous Drugs Ordinance. So Yiu-wah, president of the Society of Hospital Pharmacists of Hong Kong, noted that such a high dose of ketamine could slow a patient's breathing, potentially necessitating ventilator support to maintain adequate oxygen levels. To reduce the chances of dosage errors, So suggested limiting ketamine to a single dose size. Typically, a nurse retrieves the drug in a vial, which is then checked by another medical staff member before administration.

Although medical errors are not unheard of, the incident at Tuen Mun Hospital adds to a series of recent mishaps at public hospitals. Last month, an intern doctor at another hospital mistakenly directed a laxative into a patient’s lung rather than the stomach after misreading an X-ray. In another case in June, an incorrect X-ray reading by an intern doctor resulted in a feeding tube being mistakenly placed in a patient’s lung instead of the stomach at Queen Elizabeth Hospital.

Secretary for Health Lo Chung-mau recently acknowledged that these recurrent incidents point to deeper issues within the public healthcare system, indicating a “systemic problem” rather than isolated events. In July, the Hospital Authority formed a special committee to evaluate and reform the management of Hong Kong’s public hospitals. Lo disclosed that a report, including over 30 recommendations, was submitted to the Health Bureau in October to address these issues.

Alex Lam Chi-yau, chairman of the advocacy group Hong Kong Patients’ Voices, called the incident a “serious” medical error and emphasized the importance of handling sedatives with extreme caution. Lam voiced concern over potential human negligence, urging the hospital to notify relevant authorities, including the Medical and Nursing Councils, if there is evidence of professional misconduct. He also criticized the Hospital Authority for only acknowledging the incident after inquiries from the media, questioning why the case was not disclosed sooner. Lam speculated that there might be reasons behind the delayed disclosure and called for greater transparency to maintain public trust.

This incident underscores the need for reinforced safety protocols and diligent adherence to procedural checks to prevent future errors. The health authority’s investigation committee aims to recommend improvements to the current counter-check systems and safeguards to ensure that medications are administered safely and accurately.

Reference:

1. South China Morning Post. "Hong Kong Public Hospital Gave Patient 10 Times Prescribed Sedative Dose in Medical Blunder." South China Morning Post. Accessed October 11, 2024. https://www.scmp.com/news/hong-kong/health-environment/article/3284765/hong-kong-public-hospital-gave-patient-10-times-prescribed-sedative-dose-medical-blunder.

(Input from various sources)

(Rehash/Yash Kamble/MSM)