Caritas Medical Centre announces sentinel event
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The spokesperson for Caritas Medical Centre (CMC) announces a sentinel event today (March 5):
A 75-year-old male patient, who had a medical history of hypertension and Alzheimer's disease, started a puree diet instead of a minced diet in February this year.
The patient was admitted to CMC for abdominal pain and constipation on February 28. During hospitalisation, the patient was kept nil by mouth, and the doctor arranged intravenous therapy for him. On the morning of March 2, the patient's condition was improving, and his diet order was changed to "fluid diet" after the doctor's assessment.
The patient was reassessed by the case doctor on March 3. As the patient had bowel opened, the doctor changed the patient's diet order from "fluid diet" to "diet as tolerated". Near lunchtime, the nurse overseeing the patient interpreted the adjustment as allowing the patient to have a regular meal after reading through the diet order made by the doctor. A regular meal was therefore served to the patient for lunch subsequently.
A student nurse followed the diet order to feed the patient. The patient could chew and swallow and showed no abnormalities at the beginning of feeding. The student nurse continued to monitor his condition. However, the patient suddenly started coughing after a few mouthfuls of food. The patient developed cardiac arrest. The team performed resuscitation for the patient promptly. However, the patient's condition continued to deteriorate, and he finally succumbed at around 1.30pm on the same day.
The hospital is very concerned about the incident and is deeply saddened by the patient's passing. The hospital has met with the patient's family to explain details of the incident and extended sincere apologies and condolences. All possible assistance will be rendered to the family.
The hospital has reported the incident to the Hospital Authority Head Office. A root cause analysis panel will be set up to investigate the incident thoroughly. The investigation and recommended improvement measures will be completed within eight weeks. The hospital has subsequently devised enhanced measures to remind all healthcare staff to strengthen communication and ascertain their understanding of patients' clinical condition and treatment arrangements. The incident has also been reported to the coroner for follow-up.
The Root Cause Analysis Panel members are as follows:
Chairperson:
Dr Lau Ka Hin
Clinical Stream Coordinator (Medical), Hong Kong East Cluster
Members
Professor Chair Sek Ying
Vice-Director of Research, The Nethersole School of Nursing, Faculty of Medicine, the Chinese University of Hong Kong
Mr Chan Man Nok
Chief Nursing Officer, Nursing Services Department, Hospital Authority
Dr Raymond Cheung
Chief Manager (Patient Safety and Risk Management), Hospital Authority
Mr Lam Yan Ki
Department Manager (Speech Therapy), Kowloon East Cluster
Dr Lau Chi Hung
Chief of Service (Surgery), Queen Elizabeth Hospital
Dr Ben Wong
Clinical Services Coordinator (Surgery), Caritas Medical Centre
Ends/Wednesday, March 5, 2025
Issued at HKT 18:33
Issued at HKT 18:33
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