Pok Oi Hospital releases investigation findings on tubing incident
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Regarding an earlier incident of incorrect connection of a feeding tube to a patient's tracheostomy, the spokesman of Pok Oi Hospital announced the investigation findings today (August 19):
A Temporary Undergraduate Nursing Student working part-time in a medical and geriatric ward incorrectly connected a feeding tube to a patient's tracheostomy tube on May 22, 2016, while performing a feeding procedure. Upon noticing some drops of milk oozing out from the connection site of the feeding tube, the Temporary Undergraduate Nursing Student immediately closed the clamp to stop the feeding and notified a ward nurse. The whole process lasted for less than one minute. The ward nurse immediately disconnected the feeding tube and performed tracheal suction. Only a little sputum was sucked out from the tracheostomy with no milk found. Subsequent examination of the patient performed by doctors showed no abnormal findings.
An investigation panel was set up to investigate the causes of the incident and propose recommendations. After investigation, the panel noted that there is room for improvement in the familiarisation of some specific procedures by Temporary Undergraduate Nursing Students and the delineation of their roles and responsibilities, as well as the orientation and competency assessment provided by the clinical department.
The investigation panel has made the following recommendations to the hospital:
- The hospital or unit should provide a relevant orientation programme to all new Temporary Undergraduate Nursing Students before commencement of their clinical duties;
- Temporary Undergraduate Nursing Students should pass a competency-based assessment before being allowed to perform the respective clinical procedures;
- Clinical units should be encouraged to define a list of general patient care duties that Temporary Undergraduate Nursing Students are allowed to perform; and
- The ward/unit/hospital should define a list of high-risk or uncommonly performed clinical procedures which Temporary Undergraduate Nursing Students should not be allowed to perform.
The hospital has accepted the investigation findings and recommendations, and the report has been submitted to the Hospital Authority Head Office.
The hospital wishes to convey its apologies to the patient's family again. The hospital is grateful for the work of the chairman and members of the investigation panel.
Membership of the panel is as follows:
Chairman
- Service Director (Quality & Safety), New Territories West Cluster, Dr Tang Kam-shing
Members
- Clinical Director, HKU Health System, Professor Joseph Lui
- Manager (Patient Safety & Risk Management), Quality & Safety Division, Hospital Authority Head Office, Dr Lam Chung-man
- Chief Nursing Officer, Nursing Division, Hospital Authority Head Office, Ms Peggy Wong
- Department Operations Manager (Medicine & Geriatrics), United Christian Hospital, Mr Eric Tang
- Senior Nursing Officer (Nursing Services Division), Pok Oi Hospital, Mr Wong Chi-yuen
Ends/Friday, August 19, 2016
Issued at HKT 18:35
Issued at HKT 18:35
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