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Queen Mary Hospital announces sentinel event

The following is issued on behalf of the Hospital Authority:

     The spokesperson for Queen Mary Hospital (QMH) today (May 30) made the following announcement regarding a sentinel event:

     An 83-year-old male patient was earlier admitted to the Adult Intensive Care Unit (AICU) for management of myocardial infarction. In the morning of May 27, the medical team decided to remove the triple lumen haemodialysis catheter inserted into the patient in preparation for transferring him to the general ward as his condition stabilised. An AICU nurse removed the catheter when the patient was sitting in an armchair. About 10 minutes after the removal of the catheter, the patient felt unwell. Two AICU doctors nearby assessed the patient and started cardio-pulmonary resuscitation immediately. Spontaneous circulation returned in four minutes.

     The patient's relatives were seen by AICU doctors and were told that the cardiac arrest may have been related to venous air embolism.

     The patient's condition stabilised in the afternoon but he developed another episode of myocardial infarction the next morning (May 28). A cardiologist was consulted and medical treatment was suggested because of high operative risk. The AICU team met relatives of the patient again to inform them of this episode of myocardial infarction and the treatment plan. The condition of the patient continued to deteriorate and he succumbed in the early morning today (May 30).

     The patient was admitted to the surgical ward of QMH for post-operation assessment on May 19 after an earlier operation of dissecting thoracic aortic aneurysm. The patient fell in the ward, resulting in hip fracture, on the same day. Hip arthroplasty was performed on May 21 uneventfully. On May 25, the patient developed myocardial infarction and was transferred to the AICU on the following day.

     A triple lumen haemodialysis catheter, which can be removed by an Intensive Care Unit nurse with appropriate training, was inserted for emergency haemodialysis and for administration of inotrope. According to clinical guidelines, the patient should either be in a "lie down" or "head down" position during the catheter removal procedure to minimise the risk of air embolism.

     QMH is deeply concerned about the incident and has reported it to the Hospital Authority Head Office (HAHO) through the Advance Incident Reporting System. An Investigation Panel will be set up to investigate the incident and submit a report to the HAHO. Recommendations will be made to prevent recurrence of similar incidents.

     The case has been referred to the Coroner for follow-up. QMH expresses its deepest condolences to the family for the death of the patient and will continue to closely communicate with the family to provide the necessary assistance.

Ends/Monday, May 30, 2016
Issued at HKT 19:49


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