************************************************************
The following is issued on behalf of the Hospital Authority:
The spokesperson for Princess Margaret Hospital (PMH) made the following announcement today (December 11) regarding an investigation report on a sentinel event:
PMH announced a sentinel event on October 16 and thereafter appointed a panel, with participation of independent members, to investigate the underlying cause of the incident and make recommendations to prevent future reoccurrence. The panel has completed the investigation and the report has been submitted to the Hospital Authority Head Office and PMH.
The incident involved a 58-year-old male patient who was admitted for septic shock. Shortly after admission, he was found to have multi-organ failure and he became unconscious. He was put under care in an intensive care unit (ICU) with intubation and ventilation on October 15. However, two components (End Tidal Carbon Dioxide Module and the Heat & Moisture Exchanger) connected to the ventilator circuit were found to be in reverse sequence and required swapping. To do the adjustment, the ventilator was switched to standby mode at 5.47am on October 15, which cut down the air flow to the patient. Inadvertently, the nurse involved forgot to revert the ventilator back to operation mode afterward.
The patient developed cardiac arrest at 5.48am. Chest compression was started immediately. Simultaneously, a doctor discovered that the ventilator was in standby mode and changed it back to operation mode. The patient regained spontaneous circulation after five minutes, and was once conscious between 8am to 9am. However, the patient's condition continued to deteriorate rapidly, possibly due to the underlying uncontrolled sepsis and he was eventually certified dead at 10.45pm, which was about 17 hours after the incident. The hospital explained the incident in detail to the patient's relatives. The incident was announced to the public the next day.
The investigation panel has interviewed the staff concerned and examined the workflow. The panel has concluded in its findings that the following four factors are believed to have contributed to the incident:
(1) The nurse involved was distracted by the patient's rapidly deteriorating condition;
(2) The related guideline on changing the ventilator circuit was not strictly followed;
(3) A huge haemodialysis machine which was placed near the bed had blocked the screen of the ventilator from showing the "standby" flashing warning signal; and
(4) The ventilator in-use has no audio alarm warning signal feature while the standby mode is operated.
The panel has made the following recommendations to the hospital:
(1) To reinforce the training for ICU nurses on steps in changing components of the ventilator circuit;
(2) To enhance the existing guidelines on the steps in changing the ventilator circuit;
(3) To ensure proper arrangement of bedside equipment to minimise the chance of blocking the ventilator screen;
(4) To recommend the manufacturer to add an audible alarm signal while the ventilator is in standby mode;
(5) To consider using "suction support mode" with an alarm feature while changing the ventilator circuit; and
(6) To conduct regular audits on staff compliance with the guidelines.
PMH is highly concerned about the incident and immediate actions have already been taken to alert ICU nurses about the risk. PMH will enforce the recommendations to prevent similar incidents from happening again. PMH has explained the investigation findings to the family and again extended sincere apologies. The hospital will offer the necessary assistance. The incident has been referred to the Coroner for follow-up. Appropriate disciplinary actions will be considered according to prevailing human resources policy. PMH expresses appreciation to the Chairman and members of the investigation panel. Membership of the panel is as follows:
Chairman
Dr Law Kin-ip
Chief of Service (Intensive Care Unit)
United Christian Hospital
Members
Dr Tony Mak
Service Director (Quality and Safety)
Kowloon West Cluster
Dr Venus Siu
Senior Manager (Patient Safety and Risk Management)
Hospital Authority Head Office
Ms Chau Lai-sheung
Nurse Consultant (Intensive Care Unit)
New Territories West Cluster
Ends/Friday, December 11, 2015
Issued at HKT 18:39
NNNN
