Tuen Mun Hospital announces medical incident related to patient with temporary tracheostomy
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The spokesperson for Tuen Mun Hospital (TMH) today (August 27) announced the following medical incident concerning a patient with temporary tracheostomy:
On August 4, 2018, a nursing student who was working in a surgical ward tried to perform tracheal suction for a 61-year-old male patient with a temporary tracheostomy after learning the patient felt discomfort with sputum retention. The student attempted to perform the procedure but in vain. The patient was found to have small amount of blood-stained vomitus. The student then sought immediate assistance from a duty nurse in the ward, who took over the procedure together with other nurses in the ward to support the patient. The condition of the patient kept deteriorating and the patient's tracheostomy tube was also found displaced.
Two on-duty doctors in the ward also arrived shortly and started airway management and resuscitation for the patient. During the process, the patient developed cardiac arrest and cardiopulmonary resuscitation (CRP) was initiated immediately. The patient resumed circulation after around 30 minutes. He was then transferred to the intensive care unit for further management. The patient's condition further deteriorated and he succumbed last Saturday (August 25).
After receiving the report on the incident, the hospital management initiated on August 7 a preliminary investigation by reviewing the procedure of tracheostomy suction being performed by the nursing student, the patient's symptom of shortness of breath and the resuscitation process. According to the Hospital Authority's prevailing protocol, supervision and guidance must be provided when a nursing student is performing tracheostomy suction for patients.
TMH has been closely communicating with the patient's relatives and apologised for not adhering to the protocol whereby supervision and guidance must be provided to a nursing student for the aforementioned procedure. TMH expressed deep condolence to the relatives. The Patient Relations Officer and Clinical Psychologist have been arranged to render necessary support to them. The case has been referred to the Coroner for necessary follow-up.
TMH has reported the incident to the Hospital Authority Head Office and an investigation will be launched. The hospital has also reminded ward management staff to strictly follow the protocol that supervision and guidance should be given to nursing students when special nursing care procedures are being performed.
Ends/Monday, August 27, 2018
Issued at HKT 19:25
Issued at HKT 19:25
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