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Queen Mary Hospital announces oxygen delivery tube disconnection incident

The following is issued on behalf of the Hospital Authority:

     The spokesperson for Queen Mary Hospital (QMH) announced a sentinel event today (August 30):

     A patient was transferred from Caritas Medical Centre on August 22 for further treatment for acute myocarditis and the problem of slow heart rate. The patient was in critical condition upon admission and the condition deteriorated rapidly. Investigation results indicated parainfluenza infection and rapid decline of heart function.

     In view of the patient's deteriorating condition, in the early hours of August 24, just after midnight, the patient was taken to the operation theatre for connection to an Extracorporeal Membrane Oxygenation (ECMO) life support machine. After the operation, the patient was transferred to the Intensive Care Unit for observation and treatment. The condition of the patient further deteriorated. On examination, the oxygen delivery tube was found to be disconnected from the ECMO machine. Clinical staff reconnected the tube immediately to improve oxygen saturation in the patient's blood. However, the heart function showed no improvement. The patient was certified dead on August 28.

     The hospital has reported the incident to the Hospital Authority (HA) Head Office via the Advanced Incident Reporting System and will set up an investigation panel to identify the root cause of this incident and provide recommendations for improvement. The report will be completed in eight weeks and submitted to the HA Head Office.

     QMH expressed its deepest condolences to the patient's family. The hospital Patient Relations Officer will maintain close contact with the family and offer necessary assistance.

Ends/Thursday, August 30, 2012
Issued at HKT 20:16


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