Queen Elizabeth Hospital releases investigation findings on sentinel event
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The spokesperson for Queen Elizabeth Hospital today (December 9) released the investigation findings and recommendations on an incident which was announced earlier regarding gas bubbles emerging in the tube of a peripheral Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) machine:
The hospital announced on September 21 this year that 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 cardiogenic 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 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 (ICU) 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 ECMO tubes were checked and no cracks were found. The patient remained in 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.
Following the incident, a Root Cause Analysis panel was set up by the hospital to review the possible causes and sources of gas bubbles from the patient or from the ECMO circuit. Various possible causes of gas bubbles have been examined, including intravenous infusion procedures and possible perforation of the patient's internal organs. However, the actual cause could not be ascertained. The Panel has also reviewed the management of the incident and acknowledged that the medical staff providing ECMO care had received proper training and were credentialed, and that the department guidelines for the priming of circuit and crisis management of ECMO therapy were followed.
Noting that ECMO is a high risk procedure, the Panel made the following recommendations after a thorough review of the incident and based on the corresponding observations:
- Staff should stay vigilant for early detection and response to the change of patient's condition;
- Enhance staff awareness on the recognition and staged management of both air in the ECMO circuit and air embolism in the ECMO patient through simulation training and sharing;
- Reinforce staff training on priming of circuit. Individual competency assessment on ECMO circuit priming was suggested for nurses before independent priming of the ECMO circuit was allowed; and
- Ensure timely incident reporting and the keeping of involved equipment, instruments or consumables after the incident to facilitate subsequent investigation.
The hospital accepted the investigation findings and recommendations and the report has been submitted to the Hospital Authority Head Office. The case has been referred to the Coroner for follow-up.
The hospital has communicated with the patient's relatives on the investigation report and expressed its deepest condolences to the patient's family again. The Patient Relations Officer will provide necessary assistance to the family. The hospital also expressed gratitude for the work of the Chairman and members of the Root Cause Analysis panel. Membership of the panel is as follows:
Chairman
- Cluster Service Coordinator (Surgical), Kowloon Central Cluster/ Consultant (Anaesthesia and OT Services), Queen Elizabeth Hospital, Dr Chow Yu-fat
Members
- Nursing Officer and Chief Perfusionist, Extracorporeal Circulation Perfusion Team, Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, Mr Martin Wong;
- Chief of Service (Intensive Care), Pamela Youde Nethersole Eastern Hospital, Dr Yan Wing-wa;
- Deputy Chief of Service (Medicine and Geriatrics), Tuen Mun Hospital, Dr Yam Ping-wa;
- Nurse Consultant (Adult Intensive Care), Queen Mary Hospital, Mr Peter Lai; and
- Senior Manager (Patient Safety and Risk Management), Hospital Authority, Dr Venus Siu.
Ends/Friday, December 9, 2016
Issued at HKT 18:55
Issued at HKT 18:55
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