Princess Margaret Hospital announces investigation result on sentinel event
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Regarding an earlier announcement on a sentinel event concerning a liver biopsy, the spokesperson for Princess Margaret Hospital (PMH) announced the following investigation findings and recommendations today (March 15):
A 60-year-old male patient admitted to the Intensive Care Unit (ICU) was prescribed daily injections of anticoagulation medication (enoxaparin) for treatment of deep venous thrombosis. At 3pm on January 9, an ICU team administered enoxaparin as scheduled. At 5pm, a physician performed a liver biopsy to investigate the cause of liver enzyme derangement. Under normal circumstances, enoxaparin should be withheld for 24 hours before performing a liver biopsy.
The patient developed haemorrhagic shock following bleeding from the liver later that evening. Despite multiple radiological and surgical interventions, the patient succumbed on January 12.
Following the incident, PMH set up a Root Cause Analysis (RCA) Panel to investigate the incident. After a thorough investigation, the Panel concluded that communication between clinical teams was inadequate, and there was no prompt for reviewing anticoagulants before procedures.
The Panel made recommendations to enhance patient safety including:
- To enhance communication between parent team and consultation teams;
- To develop a preparation guide for bedside liver biopsy; and
- To revise the "Bedside Procedure Safety Checklist" to ensure checking the coagulation status, including the clotting profile, and anticoagulant medication before the bedside procedure.
The hospital has accepted the Panel's recommendations, and submitted the investigation report to the Hospital Authority Head Office. The case has been referred to the Coroner for follow-up. PMH has explained the investigation results to the patient's family and expressed condolences again. The hospital will continue to provide necessary assistance to them.
The hospital expressed its gratitude to the Chairperson and members of the Panel.
Ends/Friday, March 15, 2019
Issued at HKT 17:37
Issued at HKT 17:37
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