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Alice Ho Miu Ling Nethersole Hospital announces sentinel event
The following is issued on behalf of the Hospital Authority:

     The spokesperson for Alice Ho Miu Ling Nethersole Hospital (AHNH) announced a sentinel event today (November 27):
     A patient with swallowing difficulties and desaturation was transferred to AHNH for treatment and feeding via nasogastric tube.
     In the afternoon on November 23, the patient pulled out the nasogastric tube. After the tube was reinserted, an X-ray examination was performed and the patient's gastric aspirates were also tested for acidity in accordance with the prevailing protocol. No abnormalities were detected. Nasogastric tube feeding with feeding formula and water was recommenced the same night and in the early hours of the next day. The patient subsequently developed cardiac arrest and was transferred to the Intensive Care Unit after resuscitation by clinical staff. The clinical team reviewed prior X-ray results and found that the nasogastric tube was inserted into the patient's left lung.
     The patient's condition deteriorated and he succumbed on November 26. The case has been referred to the Coroner for further follow-up. The hospital is deeply saddened by the incident. The hospital has met with the patient's family to offer its apologies and explain the incident.
     The hospital is highly concerned about the incident and has reported to the Hospital Authority Head Office via the Advance Incident Reporting System. A root cause analysis investigation will be conducted to look into the incident. The investigation report will be submitted to the Head Office in eight weeks.
     The hospital will maintain close communication with the patient's family, explain the investigation findings and provide them with available assistance.
Ends/Wednesday, November 27, 2019
Issued at HKT 18:52
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