Prince of Wales Hospital reveals guard occasion
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The following is released on behalf of the Hospital Authority.
The representative for Prince of Wales Hospital (PWH) reveals a guard occasion today (September 18):
A 54-year-old male client, who had a history of dementia and stroke, and needed a puree diet plan, was sent out to the Accident and Emergency Department of PWH by ambulance on the early morning of September 16 due to shabby psychological status. He was confessed to a medical ward for treatment. Throughout feeding the client started choking and established a heart attack, and consequently yielded late that exact same night.
The health center is extremely worried about the event and right away released an examination. Initial findings suggested that upon admission, the client did not bring any recognition file, and a “pseudo identifier” was produced for registration. According to the client’s scientific condition, the going to medical professional provided a “diet as tolerated” order for nursing personnel to follow up. As the healthcare facility’s Dietary and Catering Management System defaults to organize a routine meal for clients signed up under a “pseudo identifier”and a nursing team member did not total inspecting the client’s previous diet plan records to change the diet plan order, a routine meal was served to the client that night.
At around 6.40 pm, the client was discovered sensation unwell when a client care assistant (PCA) started feeding the client a routine meal. The PCA right away stopped the feeding and looked for aid from a nursing team member. Upon assessment, the nursing employee kept in mind a drop in the client’s blood oxygen saturation level, and right away called clinicians to suction the client and administer oxygen treatment. Clinicians from the Ear, Nose and Throat Department and the Intensive Care Unit were likewise contacted us to help in getting rid of the foreign item in the client’s air passage. The client established a heart attack throughout the procedure, and his condition continued to weaken. He gave in late that very same night. Upon evaluating the client’s history after the event, the healthcare facility discovered that the client had actually been often hospitalised before due to underlying illness. Following speech treatment evaluation, a puree diet plan was suggested for the client due to dysphagia.
The medical facility is deeply saddened by the client’s death, and has actually consulted with the client’s household to discuss the occurrence, and extended its genuine apologies and acknowledgements. The medical facility will keep close interaction with the household to render required help.
The health center has actually created instant procedures, consisting of advising health care personnel to completely evaluate clients’ scientific conditions and diet plan orders before making meal plans, and evaluating the default meal setting of the system. The nursing employee and PCA worried have actually been momentarily scheduled non-clinical tasks.
The health center has actually reported the event to the Hospital Authority Head Office by means of the Advance Incident Reporting System. An origin analysis panel has actually been designated to examine the event completely. The examination and suggested enhancement procedures will be finished within 8 weeks. The event has actually likewise been described the Coroner for follow-up.
The Root Cause Analysis Panel members are as follows:
Chairperson:
Dr Kenny Yuen
Medical Facility Chief Executive, Tseung Kwan O Hospital and Haven of Hope Hospital
Members:
Teacher Chair Sek-ying
Vice-Director of Research, the Nethersole School of Nursing, Faculty of Medicine, the Chinese University of Hong Kong
Ms Moon Chan
Supervisor (Patient Safety & & Risk Management), the Hospital Authority
Dr Chan Tak-yeung
Deputy Chief of Service (Medicine & & Geriatrics), Kwong Wah Hospital
Ms Cheung Shuk-yee
General Manager (Nursing), Shatin Hospital
Ms Lee Lai-shan
Department Operations Manager (Medicine), Tseung Kwan O Hospital
Dr Wong Wing-yin
Specialist (Medicine & & Geriatrics), Caritas Medical Centre
Dr Linda Yu
Service Director (Quality and Safety), New Territories East Cluster