Information Note
Provisional Legco Panel On Health Services
(Meeting on 12 January 1998)

Investigation Report on Incident of Wrongly Dispensed Medicine in Cheung Sha Wan Jockey Club Clinic Dispensary


This paper informs Members of the findings of the Investigation Committee on the incident of wrongly dispensed medicine in Cheung Sha Wan Jockey Club Clinic Dispensary (CSWJCCD) and the follow-up actions by the Department of Health.


2.The Director of Health appointed an independent investigation committee comprising 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 were supported by Mrs Kathryn Wong, Assistant Director (Administration and Policy) of the Department as the convenor.

3.The Committee had completed its investigation and forwarded its report to the Director of Health on 2 January 1997. Members of the Committee held a press conference on 7 January 1997 to give a brief account of their findings. A copy of the executive summary of the report is at the Appendix.

Follow-up actions by the Department of Health

4.The report of the investigation has been accepted by the Director of Health and is accessible to the public. Action has been taken to inform parents of the children affected of the laboratory results of anti-fever syrup returned for testing and to follow-up on the health status of the children who had taken the contaminated medicine.

5.A task force, headed by a Deputy Director of Health, has been formed to oversee the implementation of the recommendations of the Committee. Dedicated pharmaceutical and dispensing staff have been re-deployed to take up the task of reviewing and re-designing the dispensing procedures at clinic dispensaries, with a view to developing a handbook on good dispensing practice for dispensers. The staffing situation of the clinic dispensing service will also be reviewed separately.

6.The Department will commence disciplinary proceedings and take other administrative actions against some of the pharmaceutical and dispensing staff involved. These will follow the normal civil service procedures.

Department of Health
January 1998


Report of the Investigation Committee on the incident of wrongly dispensed medicine in Cheung Sha Wan Jockey Club Clinic Dispensary

Executive Summary

Paracetamol Elixir, an anti-fever medication for children, was found to be contaminated with Thymol Gargle, a mouthwash, at Cheung Sha Wan Jockey Club Clinic Dispensary of the Department of Health on 25 November 1997. The Director of Health subsequently appointed a committee with members drawn from independent persons of the community to investigate the incident and to address the root of the problem. An Assistant Director of Health provided logistic support to the Members in the capacity of a convenor.

2.Members of the Committee recognised the appointment of an independent body to take charge of the investigation as a reflection of the Department's commitment to be fully accountable to the public. They also appreciated the autonomy and the assistance given to them by the Director of Health at the outset.

3.The Committee first met on 8 December 1997. After reviewing preliminary evidence collected by the Department of Health, the Committee decided to interview key officers involved in the incident, parents of the children dispensed with the contaminated medication and visit a number of clinic dispensaries and the Kowloon Medical Store. The investigation was completed on 28 December 1997.

4. The investigation showed that the earliest date on which the contaminated Paracetamol Elixir was dispensed could have been 12 November 1997. The Committee concluded that the contamination of Paracetamol Elixir was a single incident which occurred in the process of pre-packing of Paracetamol Elixir in Cheung Sha Wan Jockey Club Clinic Dispensary.

5. The pre-packing process involved the bottling of Paracetamol Elixir into 60-ml bottles by pouring from stock bottles of the Paracetamol Elixir supplied centrally by the Kowloon Medical Store. It was an accepted practice for the pre-packing to be assisted by a Workman under the direct supervision of a Dispenser or Senior Dispenser. Circumstantial evidences and laboratory test results suggested that the incident happened when a partly used stock bottle of Thymol Gargle was mistaken to be Paracetamol Elixir. The mistake could only have occurred under conditions of slack supervision of the Workman by the dispensing staff.

6.The Committee also noted that, when the contamination was first discovered on 25 November 1997, some parents of affected children were contacted by the dispensing staff of Cheung Sha Wan Jockey Club Clinic Dispensary and were given misleading information. The Committee therefore recommended that the Department considered instituting disciplinary investigation on the dispensing staff in charge of Cheung Sha Wan Jockey Club Clinic Dispensary.

7.The Committee also concluded that improvements were needed in the way pre-packing was carried out at Cheung Sha Wan Jockey Club Clinic Dispensary and the handling of the incident by the dispensing staff when the error was identified. Recommendations were also made for clear operational guidelines to be issued by the Pharmaceutical Service of the Department of Health and circulated to all staff in clinic dispensaries. The procedures, physical layout, storage of drugs and dispensing equipment of Cheung Sha Wan Jockey Club Clinic Dispensary should be reviewed to prevent the occurrence of similar errors. The Committee recommended that the staffing of the Pharmacist and Dispenser grades be reviewed for the effective operation of the dispensing service of the Department.

8. In conclusion, the Committee accepted that contacting parents of affected children by telephone was an expedient and personal way of handling the incident. In fact, parents were generally satisfied with the follow-up arrangements provided by the Department. Members noted that prompt public announcement by the Department was not possible given the misleading information provided by the Cheung Sha Wan Jockey Club Clinic Dispensary.