Source: Hong Kong Information Services
The Hospital Authority said it is deeply concerned about two recent incidents involving laser ophthalmology procedures and apologised to the public.
It noted that the Coordinating Committee in Ophthalmology issued a reminder to the ophthalmology departments in all public hospitals today to reinforce the importance of strict compliance to the Interventional Procedure Safety Policy, including verification of the laser procedure’s energy level requirements and relevant patient information.
One of the incidents involves an Alice Ho Miu Ling Nethersole Hospital patient who was arranged to undergo a macular laser treatment procedure at its specialist out-patient clinic on October 12.
During the procedure, the doctor noticed that a higher degree of laser energy output was used and discovered a deviation in the setting of the micropulse laser instrument. The setting was readjusted to the appropriate energy level immediately and the procedure was completed.
The doctor reported the incident to the supervisor. The patient was seen again on October 14 and an examination revealed that the macular edema had increased and the vision was slightly impaired. The patient was briefed on the incident and a treatment was provided. Another follow-up examination will be arranged.
The other incident involved a patient at Pamela Youde Nethersole Eastern Hospital who went for macular grid laser therapy at the specialist out-patient clinic on October 12.
Two nurses performed pre-intervention checking and a marking was indicated next to the lateral canthus of the patient’s left eye, followed by the instillation of two doses of prescribed medication to that eye.
The patient later entered the laser treatment room and sat opposite the doctor upon identity confirmation. After an Eye Care Assistant applied anesthesia eye drops to the patient’s left eye, the ceiling light in the room was dimmed for the procedure.
The doctor placed the macular laser lens into the patient’s right eye during the procedure and no discomfort was raised by the patient. After discovering the wrong treatment, the doctor immediately stopped the procedure and readjusted the equipment. The procedure was carried out uneventfully on the patient’s left eye.
A follow-up appointment was arranged and the patient was informed of the incident on October 16. The relevant department will continue to closely monitor the patient, but no obvious adverse condition was initially observed.
Both hospitals apologised to the patients concerned. The clinical teams will continue to maintain close communication with them and provide the necessary assistance.
The hospitals will set up root cause analysis panels to investigate the incidents and give recommendations for improvement. The report will be submitted to the authority’s Head Office within eight weeks.
The committee will follow up on the reports and monitor the progress of the two hospitals in the implementation of improvement measures to prevent a recurrence of such incidents.