1. Post-Procedure Complications Monitoring Programme 46th Review Meeting
Friday, 17 October 2014
4:00 - 6:00pm, 4/F, Arthur K C Li Surgical Library
Lui Che Woo Clinical Sciences Building, PWH

2. Attendance Present Prof. Paul B S Lai (Chairman)
Team 1 – Dr. Sunny Y S Cheung & Dr. Ray K W Hung
Team 2 – Dr. Yip Hon Chi & Dr. Shirley Y W Liu
Team 3 – Dr. Eric Y F Cheung
Team 4 – Dr. Andrew S H Ng
PRAS – Dr. David S Y Wong
PSU – Dr. Edwin K W Chan & Dr. Vicky H Y Wong
URO – Dr. C K Chan & Dr. Samuel C H Yee
CTS – Prof. Calvin S H Ng
Mr. Alfred Chan
Ms. Daisy Feng
Mr. Philip Yeung
Ms. Eunice Tam

3. Items discussed
Complications report – August 2014
AOB

4. 1. Complications Report – August 2014

5. August 2014 Summary (case collection progress and Complication rate)
PRS NS
PSUR
URO
CTS
Dept. total
Total cases 85 49 63 31 59 58 54 78 67
542
Missing cases 6
Non-Discharged * 4 1 2 3 14
Complication rate and Magnitude
Team 1
Team 2
Team 3
Team 4
PRAS NS
PSUR
URO
CTS
Total
No. of Complication 8 14 4 3 13 1 22 72 84 48 63 31 59 58 54 78 67
542
Complication Rate
9.52%
29.17%
6.35%
12.9%
5.08%
22.41%
5.56%
1.28%
32.84%
13.28%

6. Team 1 – Hepato-biliary and Pancreatic Surgery

7. Team 1 – Hepato-biliary and Pancreatic Surgery ( Cont’d 2/7)
A good learning case for trauma management
M&M

8. Team 1 – Hepato-biliary and Pancreatic Surgery ( Cont’d 3/7)
Dr. Ray Hung – to review the micro-organism relating to small bowel perforation causing gastritis

9. Team 1 – Hepato-biliary and Pancreatic Surgery ( Cont’d 4/7)

10. Team 1 – Hepato-biliary and Pancreatic Surgery ( Cont’d 5/7)

11. Team 1 – Hepato-biliary and Pancreatic Surgery ( Cont’d 6/7)

12. Team 1 – Hepato-biliary and Pancreatic Surgery ( Cont’d 7/7)
> 30 days mortality

13. Team 2 – Upper Gastro-intestinal Surgery

14. Team 2 – Upper Gastro-intestinal Surgery ( Cont’d 2/7)
pneumonia

15. Team 2 – Upper Gastro-intestinal Surgery ( Cont’d 3/7)
Further action : to arrange a follow-up scan for safety

16. Team 2 – Upper Gastro-intestinal Surgery ( Cont’d 4/7)
Converted open from robotic surgery

17. Team 2 – Upper Gastro-intestinal Surgery ( Cont’d 5/7)
M&M
Very difficult to identify DJ flexure

18. Team 2 – Upper Gastro-intestinal Surgery
( Cont’d 6/7)

19. Team 2 – Upper Gastro-intestinal Surgery
( Cont’d 7/7)

20. Team 3 – Colorectal Surgery

21. Team 3 – Colorectal Surgery
( Cont’d 2/4)

22. Team 3 – Colorectal Surgery ( Cont’d 3/4)
4 hours 9 minutes relatively long because of decontamination
Lesson to Learn
Early decision making
So as to minimize the OT duration

23. Team 3 – Colorectal Surgery
(Cont’d 4/4)

24. Team 4 – Vascular Surgery

25. Team 4 – Vascular Surgery
( Cont’d 2/4)

26. Team 4 – Vascular Surgery ( Cont’d 3/4)
Intra-abdominal collection
Should be a Team 3 case

27. Team 4 – Vascular Surgery
( Cont’d 4/4)

28. Plastic, Reconstructive and Aesthetic Surgery

29. Plastic, Reconstructive and Aesthetic Surgery ( Cont’d 2/3)
would enhance supervision

30. Plastic, Reconstructive and Aesthetic Surgery
( Cont’d 3/3)

31. Neurosurgery
NS Cases not discussed

32. Neurosurgery
( Cont’d 2/11)

33. Neurosurgery
( Cont’d 3/11)

34. Neurosurgery
( Cont’d 4/11)

35. Neurosurgery
( Cont’d 5/11)

36. Neurosurgery
( Cont’d 6/11)

37. Neurosurgery
( Cont’d 7/11)

38. Neurosurgery
( Cont’d 8/11)

39. Neurosurgery
( Cont’d 9/11)

40. Neurosurgery
( Cont’d 10/11)

41. Neurosurgery
( Cont’d 11/11)

42. Paediatric Surgery & Paediatric Urology

43. Paediatric Surgery & Paediatric Urology ( Cont’d 2/3)
Complication was revealed with open disclosure
Needed post-op chemotherapy

44. Paediatric Surgery & Paediatric Urology
( Cont’d 3/3)

45. Urology

46. Urology
( Cont’d 2/3)

47. Urology
( Cont’d 3/3)
M&M
Learning point - Not to put drain in closed system

48. Cardiothoracic Surgery

49. Cardiothoracic Surgery
( Cont’d 2/15)

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

51. Cardiothoracic Surgery
( Cont’d 4/15)

52. Cardiothoracic Surgery
( Cont’d 5/15)

53. Cardiothoracic Surgery
( Cont’d 6/15)

54. Cardiothoracic Surgery
( Cont’d 7/15)

55. Cardiothoracic Surgery ( Cont’d 8/15)
Should top-up nutritional support

56. Cardiothoracic Surgery
( Cont’d 9/15)

57. Cardiothoracic Surgery
( Cont’d 10/15)

58. Cardiothoracic Surgery
( Cont’d 11/15)

59. Problem of losening of suture
Cardiothoracic Surgery
( Cont’d 12/15)
Problem of losening of suture

60. Cardiothoracic Surgery
( Cont’d 13/15)

61. Cardiothoracic Surgery
( Cont’d 14/15)

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

63. 2. AOB

64. AOB
PPCMP report – will incorporate “Rolling bar chart” showing performance for each team across a time-line.
SOMIP – explore the development of risk calculator based on retrospective data (25 data fields)

65. THE END