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Tuen Mun Hospital announces sentinel event
The following is issued on behalf of the Hospital Authority:

     The spokesperson for Tuen Mun Hospital (TMH) made the following announcement today (November 9) regarding a sentinel event:

     A 49-year-old male patient attended the Medicine and Geriatrics Specialist Out Patient Clinic in the morning on October 25 with symptoms of chest pain and very low blood pressure. An electrocardiogram and other examinations showed that the patient suffered from acute myocardial infarction. According to a doctor's assessment, the patient was in critical condition and needed to be admitted for percutaneous coronary intervention (PCI). The patient was then transferred to the Cardiac Care Unit and PCI was arranged for noon on the same day.
     During the operation, when angiography was performed on the right coronary artery, air embolism of the right coronary artery was noted. The patient's blood pressure remained low and he developed cardiac arrest. Resuscitation was initiated immediately and his condition was stabilised afterwards. Doctors thereafter completed the rest of the procedures and no residual gas was found subsequently.
     The patient's blood pressure remained low and he was in critical condition after the operation. The Adult Intensive Care Unit Extracorporeal Membrane Oxygenation (ECMO) retrieval team of Queen Mary Hospital (QMH) was contacted and the team arrived at TMH in the afternoon. An ECMO was connected to the patient for supporting blood circulatory function and he was subsequently transferred to QMH for further treatment.

     The patient's condition was stabilised and he regained consciousness during hospitalisation at QMH. He received another operation this morning to connect an external cardiac assist device to substitute ECMO for supporting cardiac function. He is now in the Intensive Care Unit of Cardiothoracic Surgery in QMH with critical condition.

     TMH is deeply concerned about the incident and has reported the incident to the Hospital Authority Head Office through the Advance Incident Reporting System. An investigation panel will be set up to investigate the incident and make recommendations for improvement. The panel will submit an investigation report within eight weeks.
     TMH has met the family to explain the incident and express apologies. TMH will continue to work with QMH to support the patient and render necessary assistance to the family.
Ends/Wednesday, November 9, 2016
Issued at HKT 18:45
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