Information Note
Provisional Legco Panel On Health Services
Meeting on 9 December 1997

Monitoring of Dispensing in General Out-patient Clinic


The purpose of this paper is to provide Members with information on the incident of wrong dispensing of medicine at Cheung Sha Wan Jockey Club Clinic (CSWJCCD), the follow-up actions that have been taken, and the dispensary service in the Department of Health.


2.On 25 November 1997 a number of anti-fever syrup in 60-ml bottles in CSWJCCD were found to be contaminated with a mouthwash. The medicine was mainly given to children between the age of two months and two years for treatment of fever that might arise after immunization.

3.The anti-fever syrup and mouthwash were manufactured centrally by the Department and distributed to individual dispensaries in containers varying from 3.5 litres to 17 litres. The solutions would then be poured into small bottles at the dispensaries with the assistance of workmen. The contamination of the anti-fever syrup by the mouthwash in this incident could have occurred during the bottling process in the CSWJCCD. The mouthwash was of the same pink colour as the anti-fever syrup.

Actions taken and subsequent development

4.Information received at initial investigation suggested that the contamination occurred in the bottling process on 17 November 1997. A total of 146 clients had been issued with the syrup between 17 and 25 November 1997. All except one had been contacted and 123 had returned to the clinic for medical assessment. Out of the 117 clients who had taken the medicine, 77 had some symptoms. These were generally mild and transient. Three had been admitted to hospitals. All of them were discharged and confirmed to be well by attending doctors.

5.On 29 November 1997, the incident was announced in the mass media. A telephone hotline manned by doctors was set up to provide counselling to parents, and the CSW Maternal and Child Health Centre extended the hours of work to provide medical assessment for the clients. Samples of the anti-fever syrup collected from parents were also sent for testing.

6.On 3 December 1997, two samples of the anti-fever syrup dispensed on 15 November 1997 at CSWJCCD were tested to be lightly contaminated with the mouthwash. In the light of this finding and other allegations it was considered necessary to broaden the scale of investigation to include children who received the same kind of medicine from CSWJCCD from 1 November 1997. A special working group had been set up to conduct a full-scale investigation. Members include independent persons outside the Department, viz Dr Foo Kam-so, President of the Hong Kong College of Family Physicians, Mr Kenneth Lee, Associate Professor of the Chinese University of Hong Kong's Department of Pharmacy, and Miss Nora Yau, Director of Christian Family Service Centre. They are supported by Mrs Kathryn Wong, Assistant Director (Administration) of the Department as the convenor. This working group had been asked to fully investigate the incident and to address the root of the problem from an independent perspective.

The terms of reference of the special working group are :

  • To investigate thoroughly the incident of wrong dispensing of medicine at the Cheung Sha Wan Clinic Dispensary;

  • To review the procedure and practices in the Dispensary; and

  • To make recommendations to the Director of Health on measures to prevent the occurrence of similar mistakes in the future.

    7.The Department of Health, immediately after the incident, instituted a number of measures to safeguard the quality of medicines dispensed. Dispensary staff were reminded to exercise due care in all processes of work, including proper labelling and record-keeping, strengthened supervision of staff, the separation of utensils used for the packing of medicines for external and internal use, etc. The mouthwash was discontinued from use and alternatives were provided until a new stock of mouthwash, blue in colour, was available.

    The Dispensary Service

    8.The dispensaries in the Department of Health are manned by dispensers and senior dispensers with the support of workmen II. As at 1 November 1997, the total setup for 88 dispensaries consisted of 214 dispensers, 74 senior dispensers and 7 chief dispensers. The service is supported at the Headquarters level by pharmacists who monitor the consumption of medicines and assist in their procurement.

    9.Dispensers are certificate holders of the Technical Institute of the Vocational Training Council. The curriculum covers general pharmaceutics and related subjects like chemistry, human biology, microbiology, and accounting. There is emphasis on practical on-the-job training.

    Latest Position

    10.The special working group has already started preparatory work and devised a scope of activities to ensure thoroughness, openness and accountability. The first meeting has been scheduled on 8 December 1997. It is expected that the investigation will be completed within three to four weeks. Following the completion of work, the findings of the special working group will be disclosed.

    Department of Health
    December 1997