Queen Elizabeth Hospital announces sentinel event
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The spokesperson for Queen Elizabeth Hospital (QEH) made the following announcement today (August 21) regarding a sentinel event:
A 68-year-old male patient with severe pneumonia and multiple organ failure was admitted to the Intensive Care Unit of QEH on March 17 for treatment. Emergency operations of bowel resection and exteriorsation were conducted on April 6 and 8 respectively to deal with his massive bowel ischemia. After the operation, the patient had short gut syndrome and therefore was arranged to have total parenteral nutrition via catheter continuously to transfuse nutrition. During his hospitalisation, the condition of the patient has been gradually improving.
At 12.30pm on August 18, the patient's condition deteriorated suddenly with paralysis on the left side of his body. Resuscitation was immediately conducted and multi-disciplinary consultation from the Intensive Care Unit, Neurology, Toxicology of the Accident and Emergency Department, and Radiology and Imaging was arranged for the patient. An urgent CT scan was arranged and the result showed tiny air bubbles in his right brain, which was compatible with clinical acute stroke symptoms over the left side of his body. As the air bubbles found in the patient's brain were abnormal, the hospital classified the case as a sentinel event.
The patient was transferred to the Intensive Care Unit of QEH in the evening for further treatment. At 9.30pm, escorted by doctors, the patient was transferred to the Recompression Treatment Centre on Stonecutters Island for Hyperbaric Oxygen Therapy. The patient was transferred to the Intensive Care Unit at Pamela Youde Nethersole Eastern Hospital on August 19 at 4.30am for treatment. The condition of the patient is now serious.
After the incident, the hospital explained to the patient's family the incident and the follow-up treatment plan. The hospital will proactively follow up on the case and provide appropriate treatment in collaboration with the medical team of Pamela Youde Nethersole Eastern Hospital, and continues to communicate with the patient and his family.
After initial investigation, the hospital confirmed that the medical team had provided prompt clinical treatment to the patient. The hospital will closely monitor the patient and provide appropriate treatment. QEH will investigate the reason of the occurrence of air bubbles in his brain. The incident has been reported to the hospital management and Hospital Authority Head Office (HAHO) via the Advance Incident Reporting System. A Root Cause Analysis Panel will be formed and the report is to be submitted to the HAHO in eight weeks.
Ends/Monday, August 21, 2017
Issued at HKT 19:48
Issued at HKT 19:48
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