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The following is issued on behalf of the Hospital Authority:
The spokesperson of Yan Chai Hospital (YCH) made the following announcement today (April 30) on an investigation report and recommendations regarding a previous announced medical incident:
An independent expert panel was appointed by YCH after the announcement of an incident on March 16 relating to retention of an unexpanded stent in a patient's artery. The expert panel has completed the investigation report and made a number of recommendations. The report has been submitted to YCH and the Hospital Authority (HA) Head Office. The Hospital has accepted the recommendations made by the panel and will implement the improvement measures accordingly to enhance patient safety and to prevent recurrence of similar incident in future.
A 70 years old female, with known history of diabetic nephropathy, hypertension, atrial fibrillation and coronary heart disease was admitted for Percutaneous Coronary Intervention (PCI), which was conducted in Princess Margaret Hospital (PMH) by a Yan Chai Hospital cardiac team on March 10. In this PCI procedure, three drug-eluting stents were intended for deployment at appropriate locations of coronary arteries and to be expanded to maintain blood flow of coronary vessels.
During the procedure, one of stents was attempted to be delivered to the artery but the stent failed to be deployed and fully expanded. The stent delivery system was then retrieved. The retrieval was considered to be completed. As for the other two stents, both were deployed and expanded correctly in different locations of coronary arteries and the coronary blood flow was satisfactory. The patient was then admitted to the Coronary Care Unit of PMH for further monitoring.
In the morning of the next day (March 11), another team of cardiologists reviewed the case and suspected an unexpanded stent had been retained. The same day, YCH cardiologists conducted cardiac catheterization and confirmed that an unexpanded stent, which was considered to have been retrieved in the preceding day's procedure, had been retained in one of the coronary arteries, while blood flow was not impaired. A new stent was then deployed for the patient. After the procedure, the patient was admitted to the Intensive Care Unit of PMH for further monitoring. After five days, the patient succumbed on March 16. The hospital is very concerned about the issue and set up an independent expert panel to investigate and thoroughly review the incident for improvement measures.
The Panel concluded that the vigilance of the cardiac team was insufficient during the procedure. Moreover, staff had not fully utilised various imaging facilities to ensure proper stent deployment. The following recommendations for improvement have been made by the Panel:
(1) Enhance staff vigilance during the procedure;
(2) To establish a standard of practice for staff to follow during and after the stent deployment process;
(3) To consider using alternative measures during and after procedure to confirm proper deployment of stent, e.g. stent boost function; and
(4) To establish a robust training system for staff's further development.
YCH has accepted the findings and will implement the Panel's recommendations with reference to the investigation report. The Hospital will also commence human resources proceedings in accordance with prevailing HA policy. The patient's relatives have been contacted and communicated with. The Hospital also its expressed deepest condolences to the family members. The case has been referred to the Coroner for follow up.
The Hospital expressed its heartfelt gratitude to the Chairman and members of the Panel for their professional advice in conducting the investigation.
Chairperson:
Dr Chan Kin-wing
Consultant (Department of Medicine)
North District Hospital
Member:
Dr Rebecca Lam
Chief Manager (Patient Safety and Risk Management Department
Hospital Authority
Dr Tony Mak
Service Director (Quality and Safety), Kowloon West Cluster and Consultant (Pathology), Princess Margret Hospital
Mr Lai Ling-po
Nursing Consultant (Cardiac Care)
New Territories West Cluster
Dr Peter Au-Yeung
Senior Medical Officer (Department of Anaesthesiology)
Yan Chai Hospital
Ends/Thursday, April 30, 2015
Issued at HKT 19:07
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