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The following is issued on behalf of the Hospital Authority:
In response to media follow-up enquiries on a medication incident at Queen Elizabeth Hospital (QEH), the QEH spokesperson replied as follows:
A two-week-old baby boy was admitted for neonatal jaundice on July 18, 2008. A bronscopy was performed on July 23 to examine the condition of his respiratory stridor. Intravenous morphine 2.5mg was given for sedation during the procedure which was smoothly conducted. The baby was under close monitoring during and after the procedure, and without odd condition. While checking the medical record 15 minutes after the procedure, it was found that 0.25mg of morphine should have been given instead of the administered 2.5mg of morphine.
Immediate treatment was given to the baby boy, including antidotes for the morphine's side effects, monitoring his vital signs, blood oxygen, arterial blood gases and multiple clinical examinations and tests. No complication was found and the babyˇ¦s blood oxygen, blood pressure and pulse were normal. The baby appeared sleepy with shallow breathing, and was arousable. His breathing improved after the proactive treatment and he was transferred to the neonatal intensive care unit for further monitoring.
Following the proactive treatment and close monitoring, the residual effect of the morphine was completely resolved and the baby resumed his normal condition with smooth feeding. His parents were assured that the medication incident would not affect the babyˇ¦s health in the long run. Clear explanations to the parents were made and apologies conveyed.
The incident was reported to the Hospital Authority and the hospital management through the ˇ§Advanced Incident Report Systemˇ¨. The preliminary investigation showed that the incident resulted from the incorrect prescription of the dosage of morphine. The dosage prescribed for sedation in the incident was 4.3 times that of the suggested range of prescription dosage. The hospital has set up an investigation team to review the drug prescription procedure and the guidelines on drug safety as well as the strengthening of staff alertness on the counter-checking mechanism of related procedures. Follow up actions will be taken according to the Human Resources Procedural Manual should human error be involved in the case.
Ends/Monday, July 28, 2008
Issued at HKT 18:58
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