Tighten hospital supervision

Queen Mary Hospital carried out a mismatched heart transplant that left a 58-year-old female patient barely alive under intensive care. The hospital admitted that human error occurred in the scandal and it would form an independent panel to find out exactly what went wrong.

Hong Kong maintains stringent regulation over organ transplants but failed to prevent a heart of the wrong blood type from being transplanted. This serious mistake suggests the supervision of public hospitals is flawed and that doctors involved in the procedure were not as vigilant as they should have been. Relevant authorities must thoroughly investigate the incident, find out exactly whose fault it is and increase the supervision of public hospitals, beginning with medical process management, to eliminate loopholes and prevent such mistakes from happening again.

Replacing a failing heart with one of the wrong blood type is extremely rare, but when such a grave mistake happens, despite the multi-layered matching regime in place, something must have been woefully amiss with hospital management and/or the working attitude of the medical staff responsible for the operation.

The existing Human Organ Transplant Ordinance imposes air-tight regulation upon such procedures. It is therefore frightening to learn that the two senior doctors in charge of donor organ-matching and the transplant operation both failed to realize the donor's blood type is AB while the recipient's is A, as if the matching regime was useless.

A series of similar errors at public hospitals, including dispensing inappropriate medicine, injecting the wrong doses into patients and mismatched blood transfusions, have seriously damaged the reputation of Hong Kong's public healthcare system in recent years. One of the main causes of this sorry situation is that public hospitals have been stretched beyond capacity for too long and the government has been unable to help turn things around for them. Relevant authorities should not treat this grave error as an isolated incident. They need to review the workload of public hospital staff and tighten the organ-matching regime by optimizing clinical process management.

This is an excerpted translation of a Wen Wei Po editorial published on May 23.

(HK Edition 05/24/2013 page1)