Princess Margaret Hospital announces sentinel event
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The spokesperson for Princess Margaret Hospital (PMH) announced a Sentinel Event today (January 14) as follows:
A 60-year-old male patient attended the Accident and Emergency Department of North Lantau Hospital for shortness of breath on November 27, 2018. He was transferred to the Medical ward of PMH on the same night for further management. On November 28, the patient was transferred to the Intensive Care Unit (ICU) for respiratory failure needing mechanical ventilatory and extracorporeal membrane oxygenation support. The patient was subsequently diagnosed to be suffering from Community-associated Methicillin-resistant Staphylococcus Aureus necrotising pneumonia.
On January 3, computed tomography (CT) scanning revealed the patient had pneumothorax, multiple early liver abscesses and deep venous thrombosis. Anticoagulation medication (enoxaparin) was started for daily injection.
On January 9, due to worsening in liver function, following discussions by the ICU and medical gastroenterology (GI) teams, liver biopsy was suggested by the GI team to rule out the possibility of bacterial, fungal and mycobacterium infection. At 3pm on the same day, the ICU administered enoxaparin as scheduled. At 5pm, the GI team proceeded with liver biopsy. Under normal circumstances, enoxaparin should be withheld for 24 hours before performing liver biopsy.
Patient developed haemorrhagic shock at 8pm that night, needing blood product transfusion and stepping up of inotropic support. Contrast CT abdomen scanning revealed a large hemoperitoneum with active bleeding at the right hepatic lobe. The patient required radiological and surgical interventions for haemostasis three times subsequently.
At around 5pm on January 11, the patient's family was informed of the patient's condition. At around 5am on January 12, the patient succumbed and was certified dead.
The hospital was saddened by the incident and expressed deep condolences to the family of the patient. Necessary assistance will be provided as and when required.
The hospital is very concerned about the incident, which has been categorised as a Sentinel Event. The incident has been reported to the Hospital Authority Head Office. A root cause analysis panel will be set up to look into the incident. Recommendations will be proposed by this panel to prevent the recurrence of similar incidents in future. The report will be submitted to the Hospital Authority within eight weeks. The incident has also been reported to the Coroner.
Ends/Monday, January 14, 2019
Issued at HKT 20:06
Issued at HKT 20:06
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