Queen Elizabeth Hospital announces an incident of suboptimal oxygen support during patient transfer
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The spokesperson for Queen Elizabeth Hospital (QEH) made the following announcement today (October 1) regarding an incident related to oxygen supply during a patient transfer:
A male patient with chronic illness was admitted to QEH on September 27 for severe acute pneumonia and later developed respiratory failure. On September 28 morning, healthcare staff intubated and connected the patient to mechanical ventilator to assist his breathing. His condition further deteriorated in the afternoon with septic shock and continuously declining level of oxygen saturation. Despite high dose inotropes and enhanced ventilation support for the patient, his condition had not improved.
At about 10pm that night, with further deterioration of condition to critically ill, healthcare staff transferred him to the intensive care unit immediately for further treatment. During the transfer, a self-inflating ventilation bag was used to ventilate the patient manually. His vital signs were closely monitored during the transfer.
The patient arrived at ICU two minutes later with his pulse continuously monitored and was immediately reconnected to a ventilator. The patient developed cardiac arrest five minutes later. His heartbeat resumed after resuscitation. Healthcare staff later found that the self-inflating ventilation bag used during the transfer was not connected to an oxygen cylinder. An ad hoc interview with the patient's family was arranged to explain the incident and it was reported to the hospital. The patient finally succumbed in the morning of September 30. The hospital has referred the case to coroner for further follow-up.
The hospital is saddened by the patient's passing away and expresses its deepest condolences to the family. The hospital has met the patient's family again today to explain the incident and apologise to them. The hospital would keep close contact with them and provide them with all necessary assistance.
The hospital has reported the incident to Hospital Authority Head Office via the Advance Incident Reporting System. A review panel will be formed for thorough investigation to avoid a similar incident in the future. The investigation is expected to be finished in eight weeks.
Ends/Monday, October 1, 2018
Issued at HKT 17:30
Issued at HKT 17:30
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