Replies to LegCo questions

LCQ15: Sterilisation of surgical instruments

Following is a question by the Hon Li Kwok-ying and a written reply by the Secretary for Health, Welfare and Food, Dr York Chow, in the Legislative Council today (December 13):

Question:

Last month, doctors of the Caritas Medical Centre mistakenly used surgical knives which had not been thoroughly sterilised to perform eye operations on 13 patients, and not until a few days later was the incident discovered. In this connection, will the Government inform this Council whether it knows:

(a) the number of medical incidents involving surgical instruments or tools which occurred in public hospitals in each of the past three years, and the causes of these incidents;

(b) the results of the investigation carried out by the Hospital Authority (HA) into the incident, and the improvement measures in this respect; if it has been assessed whether the manpower for the sterilisation of medical equipment is inadequate, and whether the inadequacy has contributed to the incident; if the assessment result is that manpower is inadequate, of the solution for that; and

(c) if HA has reviewed the entire procedure for the sterilisation of surgical tools; if it has, the results of the review?

Reply:

Madam President,

(a) Apart from the recent incident involving surgical knives at the Caritas Medical Centre (CMC), there were two other incidents involving the sterilisation of surgical instruments in public hospitals in the past three years.

The first incident took place at the Prince of Wales Hospital. In 2003, the hospital performed a brain biopsy on a patient suspected of having encephalitis. The biopsy result later revealed that the patient was in fact suffering from Creutzfeldt-Jakob Disease. Upon confirmation of the diagnosis, the hospital took immediate action and destroyed the surgical instruments involved. However, prior to their destruction, the instruments might have already been used in other neurosurgical operations. Although the risk of infection to the patients concerned was extremely low, in order to avoid similar incident from happening in the future, the Hospital Authority (HA) had already revised the relevant guidelines stipulating that surgical instruments that have been used in brain biopsy had to be quarantined until confirmed diagnosis was available.

The second incident occurred in Tuen Mun Hospital. In 2004, a patient underwent a bronchoscopic examination in Tuen Mun Hospital. Subsequent to the examination, the hospital found that the bronchoscope used for the procedure had been used previously to examine a patient with pulmonary tuberculosis. Although the bronchoscope was cleansed, the sterilisation process had not been completed. After the incident, the HA gave a detailed explanation to the patient and his family and followed up on the patient's condition. The HA also made appropriate improvements to the checking procedures for reusable medical equipment after sterilisation.

(b) In respect of the incident at CMC, the HA has already set up an investigation panel to look into the cause of the incident. The investigation is expected to complete by mid December. The investigation report will be submitted to CMC's Hospital Governing Committee as well as the HA Board for consideration. After that, the HA will make the investigation results known to the public.

As the investigation is still ongoing, the HA is not able to confirm the cause of this incident at this stage. Nevertheless, preliminary findings of the investigation suggest that the incident is an isolated case involving internal delivery procedures and unrelated to the manpower for the sterilisation of medical equipment.

(c) HA's procedures for the sterilisation of surgical instruments in public hospitals have been developed in accordance with international standards. These procedures are reviewed and improved from time to time. In light of the recent incident at the CMC, the HA has already conducted an in-depth review of ancillary minor operation rooms with similar risk exposure in other public hospitals and reminded their staff to stay vigilant. During the review, the HA has not found any similar incidents that took place in other ancillary minor operation rooms in the past.


Ends/Wednesday, December 13, 2006
Issued at HKT 14:02

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