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Wednesday, July 22, 2015, 18:17

Govt aplogizes for blood analyzer blunder

By Kahon Chan / chindailyasia.com

HONG KONG - Tuen Mun Hospital staff failed to realize they had mistakenly set default reference values on a routine biochemical analyzer for two years.

Tony Ko Pat-sing, Chief Executive of New Territories West Cluster of the Hospital Authority, offered a formal apology to the public and in particular, to 9,443 affected elderly patients when he announced the medical blunder on Wednesday.

About 236 elderly male patients have been arranged to return to the hospital earlier for follow up consultation and blood tests after the hospital rectified the problem.

The device has been in use since August 2013 at Tuen Mun Hospital to analyze ten varieties of chemical content in blood plasma that are indicative of liver functions.

The device was used to analyze blood samples of 9,000 patients. Its default setting had not been checked until a routine workflow review was conducted on July 6.

The hospital realized almost two years after the device was installed that one scientific officer and chemists had erroneously swapped the male and female reference values for alkaline phosphatase (ALP) in the age range of aged 60 or above.

The reference values have been shown on patients' test reports to aid doctors' judgment. As a result of the mistake, certain male patients' ALP readings might have appeared on the report as falling in the safe range, even when they actually didn't.

Female patients might have been prompted to undergo unnecessary checks. The management, therefore, considered the risk for female patients was low, and decided to prioritize the remedial efforts for male patients.

Out of the 4,634 male patients, 1,425 have died already of a variety of reasons. Records of 2,144 male patients and 4,809 female patients are still pending review. The evaluation would take four months to complete.

Ko assured the device had always been giving accurate readings and ALP level was only one of the many factors that doctors take into consideration to determine patients' liver function.

After reviewing over a thousand of patients' records, Ko said there was no evidence that the blunder had contributed to misguided judgment on the patients' course of therapy. He also believed such a possibility was low.

Que Tak-lun, director of the hospital's clinical pathology, stressed that experienced doctors should be able to make correct judgment despite one set of confusing data.

Que also admitted it has been difficult for the hospital to realize the wrong input because it was not a practice to regularly review default settings after a device had been put into use.

The management has already identified the staff held responsible for the wrong input, but no names were given at the press conference on Wednesday and the staff were not suspended from work, since a probe was under way.

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