Caritas Medical Centre announces sentinel event
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The spokesperson for Caritas Medical Centre announces a sentinel event today (November 29):
A 79-year old male eye patient was suspected to have acute intestinal obstruction yesterday (November 28). His oxygen saturation level decreased during a transfer from eye ward to Intensive Care Unit (ICU). The patient's condition rapidly deteriorated and he eventually succumbed.
The patient had undergone peptic ulcer surgery and inguinal hernioplasty, and had also been admitted to hospital for treatments due to multiple intestinal obstruction episodes. An eye operation is originally scheduled for him today. In the morning yesterday, the patient's condition deteriorated and he developed desaturation. He was arranged an oxygen therapy subsequently. Doctors from Ophthalmology, Surgery and ICU assessed the patient's condition immediately and arranged the necessary examinations for him. The patient was suspected to have intestinal obstruction. In view of the patient's deteriorating condition, medical team decided to transfer the patient from eye ward to ICU for further treatment.
At around 11.10am yesterday, while the patient was escorted from eye ward to ICU by healthcare staff, he developed desaturation again. Despite attempting to provide higher volume of oxygen to the patient, his oxygen saturation level continued to decrease. The patient arrived ICU at 11.15am. Healthcare staff found that the valve of the oxygen cylinder used during the transfer had not been opened. Upon arrival ICU, proper oxygen supply for the patient was arranged immediately. Intubation and cardiopulmonary resuscitation had been performed by healthcare staff. However, the patient's condition continued to deteriorate and he finally succumbed at 12.50pm yesterday.
The hospital is very concerned about the incident, which has been reported to the Hospital Authority Head Office. A root cause analysis panel will be set up to look into the incident and to review the patient transfer workflow. The hospital has subsequently implemented various enhanced measures to ascertain all medical equipment function normally during patient transfer, so as to avoid reoccurrence of the incident. The incident has also been reported to the coroner for follow-up.
The hospital is deeply saddened by the passing away of the patient. The hospital has met with the patient's relatives to explain the incident, and extended sincere apologies and condolences. The hospital will continue to keep in contact with the family to offer all possible assistance.
Ends/Wednesday, November 29, 2023
Issued at HKT 23:45
Issued at HKT 23:45
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