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The following is issued on behalf of the Hospital Authority:
The spokesperson for North District Hospital (NDH) made the following announcement today (January 22) regarding the investigation report on a Serious Untoward Event:
NDH announced a Serious Untoward Event on November 20, 2015, 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 (HAHO) and NDH.
The incident involved an 84-year-old female patient who was admitted to an NDH surgical ward for suspected perforation of abdominal viscus on November 18, 2015. The patient had a history of metastatic malignant melanoma. Comfort care was agreed after discussion with the patient and her family members due to the terminal stage of illness.
The patient started receiving intravenous fluid for hydration and nutritional supplement on her left upper arm at 62.5ml/hour after admission. At 11.45am, morphine infusion was commenced at 3.3ml/hour at the patient's right upper arm to help relieve her severe pain. The hydration and nutritional fluid was increased to 83.3ml/hour. The two infusion lines were set up on a drip pole at the top-left corner of the patient's bed.
At 2pm, when the bag for intravenous fluid infusion was almost completed, a nurse brought another bag to the bedside for replacement. She instructed a pupil nurse to change the bag and continue at the rate of 83.3ml/hour. The pupil nurse inadvertently adjusted the morphine infusion pump rate from 3.3ml/hour to 83.3ml/hour after changing the bag as she assumed the morphine infusion pump was for the intravenous fluid. The nurse who supervised the pupil nurse did not notice the mistake immediately.
The error was noticed when the morphine infusion was completed in about an hour with the pump alarm triggered. The morphine infusion was stopped immediately and the case doctor was informed. The patient was kept on close monitoring after the incident. The patient's respiratory rate was 13 breaths/minute and oxygen saturation was 95 per cent at the normal level, her blood pressure remained similar to her baseline. Her condition remained ill as on admission. The hospital explained the incident in detail to the patient's relatives with apologies extended. The patient further deteriorated and finally succumbed at 7.29pm, which was around five hours after the incident. The case was reported to the HAHO through the Advance Incidents Reporting System and was announced to the public on November 20, 2015.
The investigation panel interviewed the staff concerned and examined the workflows. The panel has concluded that the following two factors are believed to have contributed to the incident:
1. Confirmation bias of the nurse learner in identifying the correct infusion line; and
2. Gap in the clinical supervision in relation to competency assessment of the nurse learners.
The panel has made the following recommendations to the hospital:
1. To review the setting up of the intravenous infusion system with inclusion of human factors to facilitate safe practice;
2. To review the clinical supervision system and strengthen the competency assessment of nurse learners; and
3. To communicate to nurses (qualified and learners) on the changes and issues related to nurse learner supervision via platforms such as an orientation programme and an experience-sharing forum.
NDH is highly concerned about the incident and immediate actions have already been taken to alert staff about the risk. NDH will enforce the recommendations to prevent similar incidents from happening again. The hospital has explained the investigation findings to the family and also extended sincere apologies again. The incident has been referred to the Coroner for follow-up. Appropriate disciplinary actions will be considered according to prevailing human resources policy. The nursing school concerned will also follow up accordingly. NDH expresses appreciation to the Chairman and members of the investigation panel. Membership of the panel is as follows:
Chairman
Dr Christopher Chu
Consultant (Anaesthesia)
Alice Ho Miu Ling Nethersole Hospital
Members
Ms Chan Lai-hung
General Manager (Nursing)
Grantham Hospital
Dr Chia Nam-hung
Consultant (Surgical)
Queen Elizabeth Hospital
Ms Michelle Wong
Nursing Consultant (Operation Theatre)
Caritas Medical Centre
Mr Fred Chan
Senior Manager (Patient Safety and Risk Management)
Hospital Authority Head Office
Ends/Friday, January 22, 2016
Issued at HKT 19:30
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