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Pamela Youde Nethersole Eastern Hospital announces a sentinel event
The following is issued on behalf of the Hospital Authority.

     The spokesman for Pamela Youde Nethersole Eastern Hospital (PYNEH) made the following announcement regarding a sentinel event today (January 20):
     A 57-year-old male patient with myocardial infarction was sent to the Accident and Emergency Department of PYNEH on January 16 due to gasping and twitching. His condition was critical and required immediate intubation. He was then admitted to the Intensive Care Unit (ICU). On January 18, the patient developed cardiac arrest at 6.30am. Upon immediate resuscitation and examination, an urgent coronary angiography and percutaneous coronary intervention (PCI) were arranged.
     The procedure was performed at 2.25pm on the same day. A coronary angiogram for the patient showed serious stenosis of his main and three coronary arteries. In view of the patient's unstable blood pressure, a doctor scheduled to set up an Extracorporeal Membrane Oxygenation (ECMO) machine before the PCI procedure to support the patient's heart function. The patient's blood pressure did not improve upon the connection of the ECMO machine at 3.53pm. A coronary angiogram was again performed which showed a sluggish coronary blood flow. Coronary arteries stenting was deployed immediately. Between 4.08pm to 4.18pm, blood pressure of the patient could not be detected and an immediate cardiopulmonary resuscitation was performed. At 4.24pm, it was noticed by the clinical team that the catheters of the ECMO machine were not connected properly to the patient's artery and vein. An appropriate reconnection of the catheters was made immediately and the PCI procedure was carried out uneventfully. The patient's blood pressure resumed as normal and he was transferred back to the ICU for further treatment. His condition remains critical.
     The hospital had explained the treatment process and extended its apology to the patient's family. The clinical team will continue to closely monitor the situation of the patient, maintain close communication with the patient's family and provide necessary assistance.
     PYNEH is very concerned about the incident. It has been reported to the Hospital Authority Head Office (HAHO) via the Advance Incident Reporting System. A root cause analysis panel will be set up to investigate the incident and recommend improvement measures. The report will be submitted to the HAHO in eight weeks.
Ends/Wednesday, January 20, 2021
Issued at HKT 19:15
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