***********************************************************
The following is issued on behalf of the Hospital Authority:
Tuen Mun Hospital(TMH) today (February 3) released the findings of an investigation concerning a 69-year-old male patient, who suffered an acute myocardial infarction and intracranial haemorrhage and later passed away.
An in-depth investigation panel found that on the day the patient was admitted to the hospital his intracranial haemorrhage was subtle. Consequently it was difficult for doctors to spot the bleeding only by reading the film of computerised tomography (CT) of the brain. The panel has therefore recommended that doctors, in addition to reading the traditional film, consider reading an electronic version of CT image in order to improve precision in high risk cases.
The patient, who had chronic heart disease, collapsed and injured his head on the morning of November 23 last year and was admitted to TMH Accident and Emergency Department (A&E). A CT brain scan and electrocardiography were ordered by the doctor. The electrocardiography findings suggested that the patient suffered from acute heart disease and the patient was transferred to the Medical Ward.
According to his medical record, the patient required aspirin and other medications for his heart disease to prevent vascular obstruction. Since the patient was in a life-threatening situation, doctors decided to prescribe him with aspirin and other drugs to improve the blood flow to the heart.
The patient's condition deteriorated after two days. He became unresponsive and required a ventilator to help his breathing. A second CT brain examination was ordered and the result suggested that the patient had suffered a serious intracranial haemorrhage. A neurosurgeon later assessed that the patient was not suitable for an operation. The Department of Medicine continued to manage the patient's intracranial haemorrhage and acute myocardial infarction with medication. However, the patient¡¦s condition showed no improvement and he succumbed in the early morning on November 27.
The electronic version of the first CT brain scan of the patient was reviewed on computer monitor and it was found that there was a small amount of blood in the patient's right frontal region. Generally speaking, patients suffering from intracranial haemorrhage are not suitable to be prescribed with anti-platelet agents or anti-coagulants.
According to the investigation report, on the day when the patient was admitted to TMH, the doctor in A&E ordered an immediate CT brain scan. Due to the urgency of the case, the A&E doctor decided on clinical management after reviewing the patient's CT brain scan film. Doctors at the Department of Medicine and the cardiologist also looked at the patient's CT brain scan film afterwards.
Members of the investigation panel reviewed the film of the patient's brain scan taken on the day of his admission and agreed that the image was very subtle, therefore it was difficult to confirm an intracranial haemorrhage in the right frontal region by reading the film alone. The panel concluded that the clinical diagnosis and judgments of doctors from A&E and the Department of Medicine were of professional standard. The panel pointed out that reading traditional scan films and electronic scan images are both practiced by doctors. However, it is more common for clinicians to view the traditional CT film.
Recommendations of the panel:
1. When dealing with high risk patients, apart from reading traditional films, doctors should also read electronic scan images.
2. When dealing with high risk patients, clinicians should consult the on-call radiologist to interpret the CT brain result.
3. For patients with head injuries, doctors should discuss with patients and families earlier on the potential risks of using anti-platelet and anti-coagulant.
TMH has accepted the investigation report and is following up on the recommendations. The hospital has also met the deceased's family to explain the details of the report and once again expressed deep condolences to them.
Since the incident, the Department of Medicine and the Department of Radiology have improved communication in the management of similar clinical conditions, in order to enhance safety of patients. TMH is also taking forward the "Filmless Radiology" project which promotes the use of electronic scan images instead of traditional films. The filmless system will be ready by the end of this year.
The investigation report has been submitted to the Hospital Authority head office. TMH will also provide all necessary assistance to the Coroner's inquest.
TMH expresses its gratitude to the Chairman and members of the Investigation Panel for their comprehensive investigation and compilation of the report. The investigation panel was chaired by the Chief of Service of the Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Dr Li Shu-kin. Other members include:
* Consultant (Department of Imaging and Interventional Radiology)of Prince of Wales Hospital, Dr Wong Ka-tak;
* Manager (Quality and Safety) of Hospital Authority, Dr Kenneth Tsang;
* Consultant (Department of Neurosurgery), Tuen Mun Hospital, Dr Yam Kwong-yui; and
* Member of Hospital Governing Committee, Pok Oi Hospital, Mr Charlie Yip.
Ends/Friday, February 3, 2012
Issued at HKT 19:40
NNNN
