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Queen Elizabeth Hospital announces sentinel event
The following is issued on behalf of the Hospital Authority:

     The spokesperson for Queen Elizabeth Hospital (QEH) made the following announcement today (September 21) regarding a sentinel event:

     A 44-year-old male patient attended the Accident and Emergency Department for chest pain at around 11pm on September 16. The patient was diagnosed with heart failure due to myocardial infarction. Inotropic agents were immediately administered for the patient. At around 4am on September 17, the patient was transferred to the Cardiac Care Unit, where he was in critical condition caused by severe shock and pulseless ventricular tachycardia.

     The medical staff promptly performed defibrillation to resuscitate the patient. The patient later underwent a Percutaneous Coronary Intervention (PCI) procedure, during which he had a cardiac arrest. Before completing the procedure, medical staff had to connect the patient to a peripheral Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) machine to supply oxygen to his blood circulation system, in order to support his cardiopulmonary functions. The PCI procedure was subsequently completed.

     After the procedure, the patient was transferred to the Intensive Care Unit for close monitoring. Around an hour later, the medical staff detected a low blood flow in the VA-ECMO system, and spotted gas bubbles emerging in the tube containing the blood flowing from the patient to the VA-ECMO machine. The medical staff immediately clamped the tube to avoid the gas bubbles from flowing back to the patient. All VA-ECMO tubes were checked and no cracks were found. The patient remained in a critical condition. The medical staff connected a second VA-ECMO machine to the patient, but he continued to have a low blood pressure and had another cardiac arrest. He finally succumbed in the afternoon on the same day.

     QEH is deeply concerned about the incident and has reported to the Hospital Authority Head Office through the Advance Incident Reporting System. An investigation panel will be set up to investigate the incident with recommendations. As a prudent measure, the hospital checked all VA-ECMO machines of the same model after the incident and no defects have been detected so far.

     The case has been referred to the Coroner for follow-up. QEH expresses its deepest condolences to the family for the death of the patient and Patient Relations Officer will continue to provide necessary assistance to the family.
Ends/Wednesday, September 21, 2016
Issued at HKT 19:00
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