Queen Mary Hospital releases investigation findings on sentinel event
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The spokesperson of Queen Mary Hospital (QMH) today (July 29) released the findings of the Investigation Panel regarding a sentinel event related to the removal of a catheter.
The sentinel event was announced by the hospital on May 30 this year. An 83-year-old male patient was admitted to the Adult Intensive Care Unit (AICU) for management of myocardial infarction. In the morning on 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. An AICU nurse removed the catheter when the patient was sitting in an armchair. About 10 minutes after removal of the catheter, the patient felt unwell. Two AICU doctors nearby assessed the patient and started cardio-pulmonary resuscitation immediately. The patient's spontaneous circulation resumed in four minutes.
The patient's condition stabilised in the afternoon but he developed another episode of myocardial infarction in the next morning (May 28). A cardiologist was consulted and medical treatment instead of operation was suggested because of high operative risk. The patient continued to deteriorate and he succumbed in the early morning on May 30. The case was referred to the Coroner.
The hospital reported the incident to the Hospital Authority (HA) Head Office via the Advance Incident Reporting System and set up an investigation panel to identify the root causes of the incident and provide recommendations for improvement. The panel noted that the nurse was not aware of the associated risks of intravascular air embolism and did not follow the standard practice in catheter removal.
The panel has made the following recommendations to enhance the safety level of catheter removal:
1. The clinical department is advised to promulgate and enhance the safer practice of removal of a catheter by putting the patient in a supine position or a head-down position unless medically contraindicated;
2. The removal of a catheter at the end of an inspiration phase should be advocated to minimise the risk of air embolism because by then the patient can only exhale even if he or she cannot effectively hold his or her breath; and
3. The department should review the content of the orientation programme, reinforce clinical coaching and evaluate the model for continuous assessment on staff performance and knowledge delivery.
The spokesperson added that the investigation report has been submitted to the HA Head Office and the panel's recommendations have been accepted. Follow-up actions will be taken according to established human resources procedures. Once again, QMH expresses its deepest condolences to the family over the death of the patient and will continue to closely communicate with the family to provide the necessary assistance.
Ends/Friday, July 29, 2016
Issued at HKT 17:40
Issued at HKT 17:40
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