Prince of Wales Hospital announces a serious untoward event
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An infant, who was born on June 12 with a maturity of less than 28 weeks, was admitted to the Neonatal Intensive Care Unit for close monitoring and treatment due to premature birth and congenital heart problems. The infant required ventilator support and inotropes infusion. As the infant presented persistent hypotension, healthcare staff adjusted the prescription of inotropes at around 3am yesterday. Infusion rate was set at approximately 0.3ml per hour, and was gradually increased to about 0.7ml per hour.
An alarm of the infusion equipment was triggered at around 3.50am. Healthcare staff immediately checked the equipment and found that the stopcock of the infusion tube was not opened, which obstructed the drug infusion. Healthcare staff promptly adjusted the stopcock and resumed the inotropes infusion to the infant. The infant's condition continued to deteriorate, and eventually succumbed at around 4pm yesterday.
The hospital is very concerned about the incident. The Hospital Chief Executive and clinical team met with the infant's relatives again this evening to explain the incident and express apology. The hospital extended its deepest condolences to relatives. Clinical team and patient relations officer will spare no effort to support and assist relatives.
The PWH has reported the incident to the Hospital Authority Head Office via the Advance Incident Reporting System. The hospital will set up a Root Cause Analysis Panel to investigate the incident thoroughly. The case has been referred to the Coroner for follow-up.
The hospital preliminarily reviewed the incident and adopted immediate measures to prevent the occurrence of similar incident, including to remind healthcare staff to be vigilant when performing drug infusion with newborn babies, for example, checking the stopcock of the infusion tube. As the infusion amount and rate are very small, healthcare staff has to ascertain the appropriate setting of the infusion equipment. The hospital will also liaise with the supplier the feasibility of enhancing the safety procedure for infusion with newborn babies.
Ends/Wednesday, June 14, 2023
Issued at HKT 23:51
Issued at HKT 23:51
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