1. Post-Procedure Complications Monitoring Programme 29th Review Meeting
Friday, 24 May 2013
4:00-6:00pm, 4/F, Arthur K C Li Surgical Library Lui Che Woo Clinical Sciences Building, PWH

2. Attendance Present Dr. Simon Wong (Chairman) Prof. Paul B S Lai
Team 1 – Dr. Anthony Fong
Team 2 – Dr. Sally Luk
Team 3 – Dr. Hon Sok Fei
PRAS – Dr. David Wong & Dr. Teresa Tan
PSU – Dr. Bess Tsui & Dr. Jennifer Mou
URO – Dr. C K Chan
CTS – Dr. Rainbow Lau & Dr. Calvin Ng
Mr. Alfred Chan
Ms Eunice Tam

3. Items discussed
Complications report – March 2013
AOB

4. 1. Complications Report – March 2013

5. Team 1 – Hepatobiliary & Pancreatic Surgery
Likely related to haematoma
All major complications in pancreas operation happened in this patient
Add : anastomotic leakage
Should be counted as mortality of PWH Surgery despite the patient died in PYNEH (since no ICU bed available in PWH)

6. Team 1 – Hepatobiliary & Pancreatic Surgery (Cont’d 2/2)
Add : Aspiration pneumonia
Note
1. The case MO should have checked the Ryle’s tube need 2. Need to remind medical staff that it is surgeons’ responsibility (not nursing staff) to check the Ryle’s tube.

7. Team 2 – Upper Gastro-intestinal Surgery
Dr. Sally Luk to review the case with Dr. Tommy Yip

8. Team 3 – Colorectal Surgery
M & M
Case

9. Team 4 – Vascular Surgery
MRSA infection in perm cath insertion : very rare
Actions
Patient cohort
Surgeon to perform nasal swab
Skin prep with alcoholic cholhexidine

10. Plastic, Reconstructive and Aesthetic Surgery
Same patient was operated twice with same complication
Team should review management logistic especially in the use of anti-coagulant

11. Neurosurgery
Became an organ donor

12. Paediatric Surgery and Paediatric Urology
Gap wound
Should consider alerting patient’s parent on the potential impact on fertility

13. Cardiothoracic Surgery
Should change to primary operation leading to complication

14. Cardiothoracic Surgery (Cont’d 2/3)
CTS team to revise principle dx before the end of May 2013 14

15. Cardiothoracic Surgery (Cont’d 3/3)15

16. 2. AOB

17. Department SOMIP Sharing Session
Date : Sat, 29 Jun 2013
Time : 10am
Venue: Auditorium, Level 1, New Block

18. END