Kwong Wah Hospital announces investigation report on injury incident of baby falling from height
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A multi-disciplinary expert panel was formed by the Kwong Wah Hospital (KWH) Hospital Chief Executive, Dr Nelson Wat, to conduct an investigation into an injury incident of a newborn baby girl falling from height. The investigation has been completed and the findings were announced today (July 19).
Dr Wat said that the hospital is very concerned about the incident. Immediate clinical examination was performed by a paediatrician, followed by X-rays, computed tomography brain scans and magnetic resonance imaging. The hospital has maintained close communication with the patient's family.
"The Chairman of the expert panel, Dr David Sun, and I explained the report findings to the family and again expressed the hospital's apology regarding the incident. We will continue to follow up with the patient's condition and provide the necessary assistance. The baby girl is currently under observation in the hospital and is in stable condition," Dr Wat said.
The multi-disciplinary expert panel was formed by KWH on June 6 to conduct an investigation into the incident in order to establish the possible cause of the incident, identify associated risk factors and make recommendations on improvement measures.
According to the investigation findings, the incident happened in a cubicle of the Special Care Baby Unit, which was divided into six open zones accommodating one or two beds or incubators each. There were seven patients, including the newborn baby girl concerned, on that day. There is a nurse working table in the centre of the cubicle. At around 3pm, the nurse set the sleeping mat at a slightly tilted position to assist the baby girl's breathing. The nurse then closed the two working windows of the incubator and covered the incubator with an incubator cover to shield the light from affecting the baby at rest. The nurse then handed over with another nurse at the nurse working table in the cubicle. There was another nurse working in the cubicle and a lady was feeding her baby with prior permission of ward staff. About 15 minutes later, three nurses in the cubicle and the lady heard abnormal noise and a baby crying. Two nurses who were handing over duties approached to check immediately. The baby girl was found lying on the floor and one of the working windows of the incubator was opened.
The investigation panel interviewed the staff concerned, inspected the cubicle and examined the incubator concerned. The window lock of the incubator concerned was designed to be silent when locking and unlocking to minimise disturbance to the baby. The expert panel considered that the incident was most probably due to an unintentional unlocking of the working window when the incubator cover was placed on the incubator, which also made the opened window stay unnoticed. Also, the tilted position of the sleeping mat positioned the baby's head at the same level as the working window. There was a possibility of her falling out of the incubator through the accidentally opened working window.
The expert panel observed certain risks associated with the operation practice and procedures in using the model of incubator concerned and, hence, made the following recommendations:
- Nursing staff should double-check and confirm whether the working windows are properly closed as indicated by the red-line safety indicator;
- Review feasible measures to place the incubator cover, without blocking the working windows; and
- Avoid tilting the sleeping mat in the incubator to position the baby's head at the same level as the working window, which may cause the baby to fall out of the incubator accidentally.
The Hospital Authority has issued a safety alert today to the clinical departments concerned using the same model of incubator. They were reminded of the identified risks and to take the necessary precautions when operating the incubator concerned to avoid recurrence of similar incidents.
KWH will co-operate with the ongoing police investigation. Dr Wat also expressed heartfelt appreciation to the panel for their efforts and recommendations, and extended an apology to the baby and the family again.
Ends/Tuesday, July 19, 2016
Issued at HKT 18:58
Issued at HKT 18:58
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