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The following is issued on behalf of the Hospital Authority:
The spokesperson of Queen Mary Hospital (QMH) today (November 2) announced the findings of the Investigation Panel regarding an incident related to the oxygen tubing connection to an Extracorporeal Membrane Oxygenation (ECMO) machine.
A patient was transferred from Caritas Medical Centre on August 22 for further treatment for acute myocarditis and slow heart rate. The patient was in critical condition upon admission and the patient's condition deteriorated rapidly with rapid decline of heart function. In view of the patient's deteriorating condition, on August 24 after midnight the patient was taken to the operation theatre for connection of the ECMO life support machine.
Following the operation, the patient's condition further deteriorated after being transferred to the Cardiothoracic Surgical Intensive Care Unit for further monitoring and treatment. On examination, it was found that the oxygen tubing was not connected to the ECMO machine. Clinical staff reconnected the tube immediately to improve the patient's oxygen saturation in the blood. However, the heart function showed no improvement and the patient was certified dead on August 28.
The hospital reported the incident to the Hospital Authority (HA) Head Office via the Advanced Incident Reporting System and set up an investigation panel to identify the root causes of this incident and provide recommendations for improvement.
The investigation has been completed and the report was submitted to the HA Head Office. The root causes of the incident identified include inadequate communication following the change of practice in the connection of the ECMO support system upon transfer of a patient; inadequate understanding of some staff members towards the tubing connection of the ECMO system; and that the loudness of the alarm volume of the oxygen saturation analyser (48.5 to 52 decibels) is not adequate to alert staff under the ambient noise level of the ward which is around 50 to 70 dB.
The panel has made the following recommendations regarding the incident:
1. Establish a communication structure to endorse change in practice and ensure staff understanding;
2. Enforce the arrangement for perfusionist or ECMO leaders to assist in between-floor transfer;
3. Update the patient transfer and handover checklists, including the different modes of set-up and critical steps in connecting the ECMO system;
4. Enhance staff training in the use of ECMO; and
5. Explore the procurement of purpose-built oxygen saturation analyser with louder alarm.
The hospital has accepted the investigation findings and the panel's recommendations. A number of improvement measures on training and checklist updating have already been implemented accordingly. The hospital will study the report in detail and follow up the case according to established human resources procedures if required. The hospital has explained to the patient's family the investigation results and expressed its deepest condolences once again to them.
Ends/Friday, November 2, 2012
Issued at HKT 19:47
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