Tuen Mun Hospital has strengthened staff training on blood-testing and sample-labelling in the wake of November's mix-up of two patients' blood samples that led to the wrong patient receiving unnecessary treatment.

The hospital today said a staff member of the Medical & Geriatric Ward mixed up the labels of the blood samples of two women aged 70 and 85 on November 11.

The hospital discovered the incident on the same day as the examination test result of one of the patients conflicted with the clinical presentation. It immediately re-examined the two patients and provided appropriate treatment.

The patients' families were informed the following day. The patients were discharged on November 16 and 19.

Incident investigation

The incident has been reported to the hospital management and Hospital Authority through the Advanced Incident Reporting System.

Hospital management met with the concerned staff members to investigate the incident and review checking procedures related to patient identification and test samples labelling.

Staff members have been reminded to be vigilant to avoid a recurrence. Pamphlets have been produced to remind healthcare staff to print labels before taking blood. An educational video has also been produced on blood taking and matching.

In view of the heavier workload the hospital has trained more phlebotomists.

The Hospital Authority said it has allocated resources on the implementation of an electronic barcode system for all blood testing to minimise the occurrence of similar events. The system will be first implemented in several pilot centres including Tuen Mun Hospital this year.