The medical mishap at Prince of Wales Hospital in which a 21-year-old leukaemia patient died involved human error and system flaws, a special investigation panel has found.

A doctor wrongly administered Vincristine, an intravenous chemotherapy drug, intrathecally instead of into the vein of the woman who died July 7.

Panel member Professor Grace Tang today said both intravenous and intrathecal drugs were delivered to the same unit at the same time with inadequate labelling.

The investigation also found that staff did not follow guidelines on checking the medication and route of administration. They were also not aware that intrathecal administration of Vincristine could cause death.

Recommendations

The panel recommended that:

* only specially trained or designated oncology staff should practise, prepare, dispense and administer cytotoxic medication;

* medical staff must follow a formal checking procedure to ensure that the right drug is given at the right dose by the right route to the right patient;

* intrathecal chemotherapy must only be administered in an area where no other cytotoxic drugs are available;

* intrathecal drugs must be administered at a different time to other systemically-administered drugs;

* Vincristine should be clearly labelled; and,

* discussion on inappropriate treatments should be included in education for doctors.

Panel member Dr Leung Pak-yin said the Hospital Authority has accepted the findings and will take follow-up action. The authority is discussing compensation with the patient's family.

The hospital said it will devise more improvement measures as soon as possible. It has suspended all clinical duties of the staff concerned and will follow up in accordance with the authority's human resources policy.